Skip to main content

Full text of "The American Journal Of Obstetrics And Gynecology(25)"

See other formats 


AMERICAN JOURNAL 

OF . , 


OBSTETRICS AND 
GYNECOLOGY 


FREU Ij. Admu 
Walter W. Cuh’man 
Harrv S. Crossen 
Thomas S. Cullen’ 
Arthur H. Curtis 
Carl H. Davis 
William C. Dakfortu 
Walter T. Dann’eruther 
Joseph B. DeUee 
Robert L. Dickinson 
Paljier Findlet 


AnvisoRT iCditorial BOAiin 

UOREUT T. Frank 
John R. I-'raser 
George Gelliiorn 
Herman K. Havd 
Barton C. Hirst 
Howard J. Ill 
F. C. Irving 
Floyd E. Keene 
Jennings C. lAr/.KXiiERG 
Frank W. Hvnch 
Franklin H, martin 
C. JErr Miller 


Reuben I’eterson 
iRIDOR C. RuniN 
John A. Sampson 
Otto H. Schivarz 
H. J. Stanoer 
Magnus A. Tate 
Fred J. Taussig 
Howard C. Taylor 
PAUL Titus 
George Gray Ward 
Benjamin P. Watson 


Official Organ or 

the AMERICAN GYNECOLOGICAL SOCIETY I THE AMI3IICAN ASSOCIATION OF OBSTETRICIANS, 
gynecologists, and ARDOMINAL SURGEONS’, NEW YORK OBSTETRICAL SOCIETY; OBSTETRICAL 
sociBTy or Philadelphia; Brooklyn gynecological society; st. louis gynecological 

SOCIETY : NEW ORLEAN.S GYNECOLOGICAL AND ORSTETRICAI. SOCIETY ; B/VLTIMORE OUSTETRICAL 
AND GYNECOLOGICAL SOCIETY ; CHICAGO GYNECOLOGICAL SOCIETY ; CENTRAL ASSOCIATION OF 
OBSTETRICIANS AND GYNECOLOGISTS ; OBSTETRICAL SOCIETY OF BO.STON ; AMERICAN 
BOARD OF OBSTETRICS AND GYNECOLOGY 


Editor GEORGE W. KOSMAK 

Associate Editor . . . HUGO EHEENTEST 


VOLUME XXV 
JANUARY— JUNE, 1933 


ST. LOUIS 

THE 11 V. MOSBY COMPANY 

1933 



COVVUllillT, 


1933 , I"' 

(.111 Pif''*'® 


0 V. 

jlcscrvcii') 




printed <’» 


V. S. 


The 


press of 
„ y. axostl/ 
St. 1 '°’“ 


Cornpot^t/ 



ADVEKTISEMENTS 


5 


READY 



USE 


NoN-Bou-Aiii.r, D&G Kaimcrid Sutures arc ready 
lor use just as thev come Iroiu the tubes. 1 heir 
extreme dc.vil)ility makes moistening unnecessary. 
Theyare strong, accurate in size and heat sterilized. 


."t 

DAVIS & 



/ 


YORK 


CONTENTS FOR JANUARY, 1933 


Original Communications 

TIxe CompHcatloiis of Raitlaiii Tliorapy In G}^lccolo;r^■. ncorsc fjrixv XVaril, 

ar.D., K.A.C.S., Nc« T<irl,-, A. 1 ' 1 

TJic TeeJiiiic ot Ilndiatian Tlierapy Jn TJtcrIac Carpiiiojnas. Ilcurv Scliiiilt/:, 

A.ai., at.n., f.a.c.s., p.a.c.h., Chtc’a;?(>, in to 

An Analysts of tlie Mcnstrxial Clianixos in Tiilierojiloiis AVoiaoii. EiRvIxi Xr. 

Jiinioson, B.S., SI.D., Saraiuic I/tikc, X. X. S2 

EpitUclial Rogcncratlon In tlie tJferliic Glniiils anil on fijc Siirfiieo ot the 

Utcrvis. GcofKO X. Pa|iuiiico]noii, rii.lD., Xciv A'ork, X. Y ISO 

TJie Reliavior of the Epifliclixuu In Exp1ant.s of Human Einloinofviiim. 

Edwin P. Hir.scli, ar.D„ and Harold O. Jones, XI.D,, Oiieafro. HI HZ 

Bilater.al Renal Ascnc.sls In Hie Feins. Associated XVItli OllKolvvilrainnios. 

Gaylord S. Batc.s, XI.D., Detroit, ailcli 41 

Report of a Case of Ovarian Emliryonia. P. J. Sarnia, XI.U„ Xl.So., F.A.C.S., 

Clvieaso, 111 " jjj 

Kraurosis A'’nlvae, XVitli a Report of 'J'liirteen Cases. M. A. Goldliercer, 

3r.D„ F.A.C.S., Nov A'crk, N. Y jjg 

On tlie Snpports of tiic Uterus. Harry Koster, XI.D., F.A.C.S., Brooklyn, 

* . . C7 

Internal Rotation of tlie Fetal Head From tlie X'iovpoiiit of Comparative 
Oiistetrles. Uonis Rndoipii, SI.S.. ai.D,. F.A.C.S., anil A. C. Ivv, Bli.D., 
al.D., Cliicacfo, 111 ’ 

Tltc Respiratory Function of tlie Dctnelied Placenta. G. R. Briuulau. R A 
3I.D„ Houston, Texsts 

iij> 

(Contimied on page 7) 


6 


AI^IEraCAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


Mothers stop pampering the child who 
won^t eat when the cause of poor appetite 

is corrected Lack of appefite-sfimuiating Vitamin B in the child’s diet may 

now be made up with delicious Chocolate flavored Vitavose 


• You warn the mother not to spoil the 
child by pampering him. You tell her not 
to coax, to beg, to bribe, or to scold, but 
the chances are she will continue to force 
food upon him unless the reason for his 
poor appetite can be found. 

Many physicians discover, on checking 
the child’s diet, that it fails to provide 
enough of the important factor which 
stimulates appetite — Vitamin B! 

This deficiency of diet may be at the 
root of the child’s trouble. 

And now it’s so easily corrected! The 
child can be given an abundance of the ap- 
petite-stimulating factor every day. With 
Squibb Chocolate flavored Vitavose! 

A delicious, appetite-building drink, it 
provides thirty times as much Vitamin B 
as milk. Three heaping teaspoonfuls in a 
glass of milk furnishes as much of this im- 
portant factor as a whole quart of milk. 

Chocolate flavored Vitavose is also rich 
in essential food iron. It contains other 
valuable minerals and nitrogenous com- 
pounds extracted from malted wheat germ. 

Mothers should be urged to use it in- 
stead of the ordinary chocolate syrups 



and powders with which they flavor milk. 

Children do not have to be coaxed to 
drink Chocolate flavored Vitavose. It’s 
not too rich. The flavor appeals to them. 

Have mothers begin now to give it to 
them every day. It may put an end, once 
for all, to the “won’t eat’’ problem. 

For convalescents, pregnant and nursing 
mothers — Chocolate flavored Vitavose 
benefits grown-ups almost as much as 



children. Patients who have been on a 
hospital diet, expectant and nursing 
mothers are especially likely to need the 
extra Vitamin B it supplies. Suggest it now 
as a diet -supplement for them regularly. 



QU 1 8 B^GiOCOL ATE 

VlWOSE 


A delicious blend of sucrose, 30 % Vilayose ( malted wheal serm extract), cocoa, skim milk, lactose; flavored with vanilla. 


advertisemejits 


7 


Asphyxia Neonatorum and Still Births 

may frequently be avoided by keeping a close 
watch on the fetal heart. 

The stethoscope designed by Morris Leff, M. D. 

greatly facilitates the localization and counting 
of the fetal heart sounds. 

Let us send you the LEFFSCOPE for 3 weeks’ trial use. 



CHEST PIECE 


Please cut out and mail 
tilts coupon now. 


Leffscope 

comjilete 



O. & G. Supply Company 
21 East 111th Street, 

New York, N.y. 

Please send me, without obliga- 
tion, the LEFFSCOPE, for three 
weeks' trial. 


CONTENTS-^Continned 


The BercovUz Tost for Prop.iianc>-. Artlmr G. Kliijr, New Orlenns. Ea. 

Varicose Veins of Pre^jiianoy. Xornian .f. KilUonrne. M.D., Bos AufTclcs, 
Calif. 

Congenital Pncninoiiia of tUc StlUUorn nnrt tlic Newborn. .Tosepli Kalilor, 
M.O.i BrooUlyn, N. Y 

Snbncutc Bacterial EnilocariTltis as a Coniiilioation of Pregnancy. 'William 
P. nicuKcrt, M.D., PiiilaUcliibia, Pa 

Hcart-BlocU in Prcg,iinnt Women. .1, P. Grccnliiil. M.IJ., Cbleafto, 111. ...... 

Some Crologric Complications in tlic F'emnle. G. ICoIls'cIicr, jll.D., Cbicafto. 
Ill 

The IXse of Adrenalin in tlie Treatment of Acute lavcr.sion of llte Puerperal 
Uterus. WItli Report of a Case, .loliii A. Urncr, jU.D.. Pli.ll., Slin- 
neapolls, illinn 

A Case of UaryuRcal Dlpbtlierin Coinplleatlns tbc Piierperinin. .1, Ilersli, 
M.D., PlttsbiirKli, Pa 


tlniulue lasuIUation Treatajent of Trielioinonas A’^adinalls. Preliminary Ilc- 
port. Julius H. Sure, M.Tl., and .Tames E. Beveey. jlI.lJ., jWiUvaukcc. 
Wis 

Blood Chemistry Studies of Yormal Newborn Infants. Albert W. Jloliiiaii, 
SI.D., and Albert Matliien. M.»., Portland, Ore 

Ureteronepbreetomy Darina; Early PrcKiianey. B. B. McKaifilit, HI.D., 
P.A.C.S., and Keid Patterson, M.D., Charlotte, N. C. 

Hyxiei'trophy of tlic Clitoris: Rciiort of Two Cases. Lyman W. Mason, M.D., 
Denver, Colo 


(Continued on paffe 8) 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGT 


AVOID IMITATIONS! 

STRONGEST Specify MATEX 

Ihe ORIGINAL 
Latex Glove 


TOUGHEST 

THINNEST 

SAFEST 


• IMMUNE TO 
SHELF AGEING 

• WITHSTANDS MOST 
STERILIZATIONS 

• MOST ECONOMICAL 

Leading surgical supply houses can 
supply Matex Anode Process Gloves 
at $4.00 per dozen. 



If WO.u.^rjOr?*^ 

SURGEONS''*'! 
GLOy^iS / 


THE MASSILLON RUBBER CO. 

MASSILLON OHIO 

World's leading manufacturer of surgeons gloves 

(Guaranteed to comply with commercial standard 
specifications CS 41-32 and CS 40-32) 


CONTENTS — Contintfed 

Cj'siiiosis of file .Ve^vliorii, I-'iUvaril II. Ileiineii. Tl.T).. T''’..V.C.S., New York. 


N. Y 1-1T 

Iliipfnre of a Corpiis I.iifoiiiii as a Cau.se of .Veiile .Vliilomiiinl Sy>iu>foni.«. 

Waverlj- n. Payne, .Tl.lJ., F.A.C..S., Newport .New.s, V;i l.TO 

Entraneo of I.ipioilol Into Ovarian and Ollier A’eins TJiiriiip- Uleroffrapliy, 
.folin Cli.'irle.s Kllroe, It.A.. ill.D.. mid Alfred .11. Ilellninn, ll.A., It.D., 


Keporf of flic Kesnll-s After T%velve Yenr.s. in ii Cn.se of Ureferovesieal 

Annstoniosis. II. Dawson Eiirnis.s, II.U., New York, N. Y 15-1 

An Instrninent to Outline flie Pfmincn.sflel Inelslon. Sydney S. Seliocliet. 

11. D., and .luliiis E. Lackner, M.D., Chiea^ro, 111 155 

A Case in Wiiieli Scvei-al Foreiprn Ilodies IVerc Found in tlie A'asrinn of a 

Feeljle-llinded Psendoiierinaplirodite. Dr. IT. A. I.ifvendniil 15(1 

Deport of a C.tse of Velanientoii.s Insertion of the Cord IVifli Itiiptiii-e. and 

Suliseimcnt Death of Fetus in Uteru.s. Dr. Henry Ii. Iloley 15(1 

Report of a Ca.se of Yellow Atrophy of the Diver in the Latter Part of 
Prccrnaney, TVIfh Recovery. Drs. Cameron Diincnn and Glen R. Mac- 
Daehlan 157 


Society Transacdons 

Society Ti'ansaction.s 1(10 

Department of Reviews and Abstracts 


Selected Alistrjicts — BiKloinctrinin . 1(?1 

Items— Am evi can Board of Olistetric.*; and Gyneeolojarj* * Ifi-I 



ADVERTISEMENTS 


H E AT / bUrutzeu 


No bacterial life can withstand the bear 
sterilization to which all D^G SutUJ'cs 
arc subjected; therefore they arc 
sterile under the most rigid 
bacteriologic tests; . 









^KLYN, N.Y. 


CONTENTS FOR FEBRUARY, 1933 


Original Communications 

The (lunliflcntloiis ot tlic SiieclJilist. President’s Address. AVnlter T. 
Dnnnreiillier, M.D., Neiv York, AT. X. 

Some Pliascs ot tlie Toxemias ot Premuuicy. Uctliel Solomons , SI.!)., 
F.U.C.P.I., P.C.O.G., Uulilln 

New aiethods of Study Applied to aiaternal Mortalities in the Hospital. A. ,T. 
SUcel, M.D., F.A.C.S., Cleveland, Oliio 

Prevention and Control ot Morbidity nnd Mortality From Puerperal Iiifec- 
tioii Ijy State or Municipal Supervision nnd Inspection. Clmrles S. 
Bacon, Pli.B., M.D., D.Sc., F.A.C.S., CUicaKO, 111 

A Study In Correlation of tlic Sedimentation Test, Fllanicnt-Nonniamcnt, 
and tke IVliite Cell Count in Gynecolopry. II. ■\VelltnKton Yates, M.T)., 
David M. Davido-\v, M.D., FIlKnbctli Putnam, and Frances Fllmnn, 
Detroit, Mich 

Tlie Belntionsliip Betnecn Bxnarenons Tliront Streptococci and Puerperal 
Infections. Poster S. Kellogg, ai,D., nnd Artltnr T. llertig, M.D., 


Boston, Mass. 


( Continued on page 7 ) 


6 


AMKRICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


Help mothers end this trying, daily scene I 


1 


The chiid’s appetite can often be stim- 
uiated by providing extra Vitamin B 


You may painstakingly explain to mothers 
that by threatening, coaxing, and scolding, 
they only encourage the child not to eat. 

Frequently, there’s a reason for the 
child’s poor appetite which requires the 
attention of a physician. It may not be a 
problem of behavior but of diet. 

The little food which the child does eat 
often fails to supply him with enough of 
an important factor. This is the factor 
proved to be essential for good appetite 
— the appetite-stimulating factor — 
Vitamin B ! 

It’s surprising to see how many chil- 
dren who are finicky at the table fre- 
quently show a lively interest in food 
when they are given some additional* 
source of Vitamin B regularly. 






And now it’s easy to enrich their diet 
in this factor. With a delicious Vitamin B 
rich drink made with Squibb Chocolate 
Flavored Vitavose! 

Three heaping teaspoonfuls of Choco- 
late flavored Vitavose, added to a glass 
of milk, supply as much Vitamin B as a 
whole quart of milk. 

It also provides iron for the blood and 
other water-soluble minerals and nitro- 
genous compounds which greatly help to 
build children up. 

Made from malted wheat germ, it gives 
children extra nutritive factors that are 
not supplied by ordinary chocolate milk 
drinks. 

They like the taste of Chocolate flav- 
ored Vitavose, too! It makes a delicious 
drink — not too rich — just sweet enough. 

Have the mother give Chocolate flav- 
ored Vitavose to the child who needs this 
extra Vitamin B supplement regularly 
with his meals and after school. 


QU I B B/; Chocolate 

yiw/osE 

A delicious blend of sucrosef30% Viiarose ( malted ndteag germ extract), cocoa, skitn.tnilkt lactose; flavored with vanilla. 



ADVERTISEMENTS 


Asphyxia Neonatorum and Still Births 

may frequently be avoided by keepins a close 
watch on the fetal heart. 

The stethoscope designed by Morris Leff, M. D. 

greatly facilitates the localization and counting 
of the fetal heart sounds. 

Let us send you the LEFFSCOPE for 3 weeks’ trial use. 


nZ3 CHESTPIECE 


Please cut out and mail 
this coupon now. 



CONTENTS-..Cotitmued 


lujury to Ureters Iiicinaiiie: Acclilcntnl I.ii^ntion During Pelvic Oiieriitlons. 
Quitman X3. Xe-well, ar.D„ P.A.C.S., St. Eonls, Bto 

PorelBii Bodies Lett in tUc Altdonicn Alter Oucrntlon. .1. P. Grccniilll, 
ai.T)., Clilengo, 111 

Sismoidoutcrinc and Vesleoutcrlne Fistula ns a CnmpUcatiou ot Clilldlilrtli. 
Walter C. G. Klrcliner, BI.D., St. Bouis, Mo 

Blultlple Dermoids of the Ovar?-. .lames Rnirlnn Miller, M.D.. Hartford, 
Conn 

Prolapse of the Uterus. AV. A. Coventry, M.D., anil nu.sscl .1. Moc, BI.D., 
Duluth, Minn 

A Report of the End-Results of 554 Consecutive Hysterectomies. Uouls E. 
Phnnenf, ai.D., F.A.C.S., and aiauricc O. Rclson, M.D., Boston, Mass.. . 


Placenta Aecreta. E. Dec Dorsett, ai.D., St. I.ouis, aio 

Endometritis and Physometra Due to M'^clcli Bacillus. Frederick H. Falls 
ai.D,, Chicago, 111 ’ 


i Coniinued on page 8 ) 



8 


AMERICAIS^ JOURNAL OF OBSTETRICS AND GYNECOLOGY 


Msiex Anode Process Examination Cols (one or two 
finger styles) specifically designed for vaginal and rectal 
examinations. Cleaner. Safer. Made as good as MATEX 
GLOVES. All Matex Anode Dealers can supply them 
at $3.00 per dozen. 



CONTENTS^Continued 

I’lierpcml Seiisfs! IJ. WoIchU, Knlnl Types. A. F. LnsJi, Flt-D., 3f.n.. 


Clilcnsro, 111 2SS 

Enteroutcrine Flstuln. W. C. niinfortli, U.S.. .H.D., F.A.C.S., ami .lames T. 

Case, M.D., D.Sl.n.E. (Camli.), F.A.C.S., Evanston, 111 .‘lOO 

Report of a Case of Congenital Oefect in the Ilinphratmi. Charles A'eiv- 
herger, S.H., 3I.IJ., Chicago, III 

A Case of Lcncoplakia of the Vnlvti Follo<vc»l hy Careinoiua Developing in 

the Sear of the Vulvectomy. Dr. E. AV. Fischmann, Chicago, III liOO 


Society Transactions 

Society Transactions aitl 

Department of Reviews and Abstracts 

:u2 


Selected Abstracts 



£ 






DAVIS & 


\ '"i autoclaving or 

Nv . boiling does not 

affect the physical in- 

^3^ *cgnty of these sutures. 


ilil?il^<l» STREET - BROOKLYN, N.y. 


CONTENTS FOR MARCH, 1933 


In Alciiioriam — WUliaiii I’liillliiN Gravc.s Ul” 


Original Communications 


Lesions of the Placental Vessels. Tlinddeus I.. UlonlKomerj', M.D., Plilla- 

dcliiliia, Pa 320 

A. Clinical Study of 100 Cases of Devcloumentnl and Kunctional Ilellclcncics 
In tlie Female IVltli Analysis of Treatment and Results. IV. H. Cary, 
ai.D., New York, N". Y ;!33 

Ovarian Struma: A UforiilioIoKlc, Pliarmncnlu:;ic, and Rioloa'ic Examina- 
tion. Alfred Plaut, M.IJ., New Y'ork, N. Y n.ll 

The Use of rolllculln in Involutional States. Elmer L. Sevri:iKli:ius, H.D., 

Madison, IVls aoi 

Radiation Tlierapy in Gynecolosic Mnliarnancy. Ira I. Kaplan, B.Sc., M.IJ., 

N'ew Y'ork City IKJS 

Information Regarding: Gonorrlica in tlie Immature Female. Goodrich C. 

Scliatifller, M.D., and Cliiford Kuhn, M.D., Portland, Ore 374 


( Continued on page 7 ) 



6 


AJtERICAN JOURNAIi OP OBSTETRICS AND GYNECOLOGY 


Should mothers order the child to eat? 

. . .why not help make him want to eat instead? 


MT yoOR BREAD AND BUTTER! 



Made from malted wheat germ, Choco- 
late flavored Vitavose also provides iron 
for the blood and other water-soluble 
minerals of which growing children are 
likely not to get enough. 

No other chocolate milk drink that 
mothers can offer children will give them 
the supplementary factors that Squibb 
Chocolate flavored Vitavose provides. 

Appetite as well as weight will improve 
with this extra help daily! 

Children like to drink Chocolate 
flavored Vitavose. It has a delicious, mild 
chocolate flavor — not too sweet. Recom- 
mend it daily, at mealtime or after school. 


• There’s often a reason for the child’s 
poor appetite which no amount of coax- 
ing or scolding can overcome. Something 
may be holding back his normal appetite! 

With many children, it is the failure 
to get enough of one factor which is 
essential for good appetite. This is the 
important appetite-stimulating factor — 
Vitamin B! 

Often the child’s regular diet must 
be replenished with Vitamin B before 
normal hunger can return. 

This can easily be done now, with the 
help of a delicious, appetite -building 
drink — Chocolate Flavored Vitavose! 

Three large teaspoonfuls of Chocolate 
Vitavose, added to a glass of milk, give 
it the Vitamin B value of a whole quart. 



Fine lor expectant and nursing mothers! 
. . . They need much greater amounts of 
Vitamin B. Vitamin B helps to enrich 
the quality of their milk, makes it better 
for the baby. And it’s no problem to give 
them a regular Vitamin B supplement 
with Chocolate flavored Vitavose avail- 
able. It’s such a pleasant drink, so easy to 
digest. Suggest it for mothers every day. 



This delicious drink, given regularly to 
the child who won^t eat, helps create 
an appetite! Thirty times as rich as 
milkin appetite-stimulating Vitamin B. 



A delicious blond of sucrose, 30^o Vitavose (malted wheat germ extract), cocoa, skim milk, lactose} flavored with vanilla 



ADVERTISEMETSITS 


7 


Asphyxia Neonatorum and Still Births 

may frequently be avoided by keeping a close 
watch on the fetal heart. 

The stethoscope designed by Morris Leff, M. D. 

greatly facilitates the localization and counting 
of the fetal heart sounds. 

Lei us send you the LEFFSCOPE for 3 weeks trial use. 

. — _ 11 ^ Please cut out and mail 

. CHEST PIECE' coupon now. 



CONTENTS — Continued 


Siioiitnncons Kvalutioii ot the Fetus in Trniisverse Fresentntion. Nicholson 

J. Fastninn, 9I.D., Baltimore, Md. 3S2 

Postmenopausal Dlecdtni?. Samuel M. Geist, 3i.D., and Ulorrls Hiatus, Hl.tl., 

New York, N. Y. 3SS 

A Clinical Pathologic Study of 303 Consecutive Abdominal Hysterectomies. 

A. Samuels, 3I.D., F.A.C.S., and E. S. Edlavltch, A.B„ Hl.D., Baltimore, 
aid 307 

Do Sperm Hlorpliology and Biometrics Beally Otter a Reliable Index of Fer- 
tility? G. L. aiocnch, BI.D., Nciv A'ork, N. Y 410 

Vesicoureteral Reflux as an Etiologic Factor in Pyelitis of Pregnancy. 
Harold I.. Hlorris, ai.D., F.A.C.S., and dames F. Brunton, M.D., 
Detroit, Hlich 414 

An Account of a Year’s Seiwicc in Obstetrics at the Blorrisania Hospital: 

A Public Institution. Harry Aranow, W.D., New I'ork, N. Y 420 

A Survey of Cesarean Sections Performed in Philadelphia During 1!)31. 

Clifford B. Lull, HI.O., Philadelphia, Pa. 42<5 


(Continued on page 8) 


8 


AIMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


19 se THIS GLOVE on every 


OBSTETRICAL CASE 

Exact in every detail — Matex Anode Obstetrical Gloves are 
thinner, allowing greater finger facility; stronger, resisting 
unusual strain of wrist pulling; tougher, withstanding 
more sterilizations than any glove you have ever used. 



The EXTRA LENGTH and perfected shape make this 
the ideal glove for every obstetrical case and the only 
practical glove for versions. 

Leading hospital supply houses can supply Matex Anode 
Process Obstetrical Gloves at $2.00 per pair. Sizes, 7, 
71 / 2, 8 and 8%. 




P 

the MASSILLON RUBBER CO. 

SUrVwCw|\|5 ^ WOf?t.D*S CCADINO MAHUfrACTUnERS OP SURGEON'S GLOVES 

GLOVES MASSILLON, OHIO 


CONTENTS— Continued 


Cystic FHirold AVcIkIiIiib: Forty-Seven Finmils junl SliutilntlnK nn Ovnrlnu 

Cyst. .r. P. Grccnhlll, M.n., Chicnijo. Ill -MO 

Snbmucous Klyonii, CoiiiiilicntliiK the Piierpcrlnni. Ilcrimril AInnii, ai.D., 
F.A.C.S., and Henrietta IjOircnliiirK, M.D., Phllndeljililn, Pa 

Tumors of the Round EiK'nmenf. Cyrus F. Horlnc. 3I.D., Ualtlinore, Aid. . . 44G 

A Case of Fctoiiin Cordis. Cliarles I.inisrcn, 31.0.. Pliiladelidiia. Pa 44!) 

Instrument PacililatinjT Atranmatle Palpebral Separation in the Netvborn. 

Blario A. Castallo, BI.D., Providence, R. 1 451 


Society Transactions 

Obstetrical Society of PiiHadeliiliin 452 

New York Obstetrical Society 452 

Department of Book Reviews 

Book Reviews 453 

Item— -Aiiierienji Board of Ob.stetric.s niid GynccoTopry 404 


ADVERTISEjMENTS 


5 


Uniform Size and Strength 


^ r' ■ 
/ 




I 

. 1 

D&.G Sutures have always been noted for their uniformity of size and 
strength. This uniformity is the result of the utmost care in the selection 
of materials and in their processing; plus positive checks at every step. 

DAVIS & GECK, INC. - 217 DUFFIELD ST. . BROOKLYN, N. Y. 



CONTENTS FOR MAY, 1933 


Original Communications 

The Volumetric Dctcrminntlon of Amiilotic Flulil With Coiipro Red. Willliim 
.T. DiccKmniiii, n.S., II.D., niifl HI. Edrvnril Dnvis, B.S., M.D., Cliicni^o, 

III C2a 

Hj-pcrtliyroldlsm Associated With Prcpriiniicj-. Frcderlclv A. Botlic, 31,1)., 

Philndclphln, Pa , «2S 

Coiicemlngr Death of the Fetxis lu Presunney. J. Stuart Lntvraiice, 3I.D., 

Phlladeliihia, Pa C33 

An Experimental Study of the Elfects of Intravenous Inicctions of Hyper- 
tonic Glucose Solxition (50 Per Cent) on the Circulation of the Cat. 
Vincent P, Blar-zola, 3I.D., and 3Inrcus A. Torrey, B.S., Brooklyn, N. Y. 043 

Conization of the Uterine Cervix. Slortiincr N. Ilyams, 3I.D., F.A.C.S., New 

York, N. Y 053 

The 3Iechnnism and 3Iana«:cmcnt of the Tlilrxl Stnfre of Labor. Slurray L. 

Brandt, 3I.D., New York, N. Y . 002 

lujury of the Urinary Bladder Followiiii? Irradiation of the Uterus. Archie 

L. Dean, .Ir., New York, N. Y 007 

A Clinical Study of Avertin in Gynecology and Ohstctrles. George Gordon 

Bemis, 3I.D., New York, N. Y C77 

Pelvic Sympathectomy for Pain in Carcinoma of the Cervix. Charles Augus- 
tus Bchney, M.D., Philadelphia, Pa 

Psychogenic Factors In Functional Female Disorders. Karen Homey, 3I.D., 

Chicago, 111 ■ 004 

The Irregularity of the Blenstrual Function. Edward Allen, 3I.D., Chicago, 

705 


( Continued on page 7 ) 



6 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


Mothers baby the nibbler instead of 
learning what causes poor appetite * • * ♦ 


Lack of Vitamin B in the child's diet 
is often to blame 


It isn’t at all unusual for the physician to 
find that the root of the child’s trouble lies 
in her diet. 

Mothers fail to realiae the condition. 
They think that coaxing will bring back 
appetite. 

Actually, the child may need more of 
the important appetite-stimulating factor 
—Vitamin B! 

Children respond quickly to the enrich- 
ment of their diet in this factor. Instead 
of just picking at their food, they begin to 
eat heartily. Gain of appetite is often fol- 
lowed by a gain in weight. 

The next time a mother asks you how to 
break her child of nibbling, suggest giving 
extra Vitamin B. 

Have the child drink Chocolate Savored 
Vitavose regularly every day! 

This delicious food drink helps to make 
up for a lack of Vitamin B in the child’s 
diet and to restore normal, healthy appetite. 


ScmiBB 

Chocolate 

fLAVORCO 

Vitavose 

A iMidna f)od 

rffh in 

i'itj’nifit B anJGanJtm 




Three heaping teaspoonfuls in a glass 
of milk supply as much Vitamin B as a 
whole quart of milk. 

Chocolate flavored Vitavose is also rich 
in iron and nitrogenous compounds of the 
wheat embryo that growing children need. 

Children who are thin and pale thrive 
on it ! And they enjoy this food drink. 

Have mothers give it to them every day! 
Tell them to use it instead of ordinary 
chocolate powders and syrups which flavor 
milk but do not provide accessary factors. 

For the child who won’t eat — Squibb 
Chocolate Savored Vitavose! 


UnBavored Vitavose, a Bne milk-wodiBet lot ialaats 
—The anorexia that is prevalent among babies often 
comes from a deficiency of Vitamin B in cove’s milk 
and even mother’s milk. Using Vitavose or Dextro- 
Vitavose as a milk-modifier for these babies often 
gives them an appetite. To begin infant feeding, 
recommend Dextro-Vitavose, the modified product. 
When babies become accustomed to the flavor, change 
to Vitavose. f 100 times as rich as milk in Vitamin B.) 


A delicious food drink which helps 
build an appetite in the child who 
won’t cat. It is thirty times as rich 
as milk in Vitamin B. Have moth- 
ers give it regularly every day. 



A delicious blend of sucrose, 30% Vitavose ( matted wheal germ extract), cocoa, skim milk, lactose; flavored witlivanilla 



ADVERTISEMENTS 


7 


Out of di£ Sihodow Sickness 



CIBA COMPANY INC., NEW YORK, NY [ 


SISTOMENSIN. "CIBA" 

affords relief lo many sufferers of dys- 
menorrhea, metrorrhagia and other 
manifeslorions ol ovarian Viormone 
deficiency. Being in lipoid form, Sislo- 
mensin is much more stable and exerts 
Its Influence over o correspondingly 
greater period of lime than is true of 
aqueous preparations. Sisfomensin is 
doubly stondardized by the Allen- 
Doisy and Growth Tests. 

AGOMENSIN. "CIBA" 

it commonly prescribed for functional omen- 
orrbeo, ollgomenorfbeo, delayed menttruo- 
tion, etc. This water.soluble ovarian substance 
obtained from wbote ovaries couses a pro- 
nounced hyperemia of the genltol orgont, 
itlmototes ovorion function, end octlvotes 
menstruation. 

PR.OKLIMAN, "CIBA" 

Is Ideally suited for treatment of patients with 
menopousot disturbonces. It Is o combinotion 
of SIstomeniln with other outstonding thera- 
peutic agents, and hot produced eicetlent 
cllnicol results. 



CONTENTS — Continued 


Diabetes and Preaniaiiey. .Tosluia RoiikIicIiii, SI.D., nroiiklyii, N. V 710 

Primary Carcinoma of Bartliollii's Glanil, W'. Boisoii Harer, M.D., P.A.C.S., 

Philadelphia, Pa 714 

Doderloiii’s Baeillus in tlie Treatment of ATipriiiitis. Boy AV. Bloliier, Itl.D., 

F.A.C.S., and Claude P. Brown, ni.D., Pliiladclphla, Pa 71S 

Ascliheim-ZoiideU Projiiaiiey Test, Friedman Modiiication. Bernard Manii, 
M.D., P.A.C.S., David Meraiir.e. M.D., and Dcih Goluh, lil.D., Philadel- 
phia, Pa 733 

Injuries to the A'^aKiua IVcsultinp: Prom the Elliott Treatment. Samuel A. 
Cosprrove, jil.D., P.A.C.S., and Edwaril G. AA'’aters, AI.D.. P.A.C.S., Jersey 
City, IV. J 731 ) 

Tuhal PrepTuaucy Following llteriiic Iiiseniiiiatioii. It. A. Difvcndnlil, M.D., 

Chicago, III 733 

Report of a Case of Teratoma of the Uterus. .Tiilins E. Dackner, M.D., and 

Ijcon Ivroiiu, 9I.D., Cliieafto. Ill 733 


Gummas of tlic Urinary Bladder. AValter E. Bevy, M.D., and Carl J. Tripoli. 
M.D.. IVew Orleans, Ba 

Report of a Case of Myomectomy for an Interstitial Fibroid Complicated by 
a A^ery Early Preprnaney. Hiram N. A’^inehcrR-, M.D., New York, N. Y. 

Complete Placental Detachment AA^ith Apoplexy of tlie Uterus RenniriHR- 
Hysterectomy. Dr. M. B. Bcvcntlial, Cliieafto, 111 

Report of a Case in AVliich a Stem Pessary Had Been Embedded for Fifteen 

Years in the Uterus. Fred B. Adair, M.D., CliicaKo, 111 75 P 


743 


74G 


74S 


(Continued on page 8) 



8 


ASIERICAN JOUEXAL OF OBSTETRICS AXD GYXECOLOGY 


AVOID IMITATIONS! 


• STRONGEST 

• TOUGHEST 

• THINNEST 

• SAFEST 

• IMMUNE TO 
SHELF AGEING 

• WITHSTANDS MOST 
STERILIZATIONS 

• MOST ECONOMICAL 

leading surgical supply houses can 
supply Mate* Anode Process Gloves 
at $4.00 per dozen. 


Specify MATEX 
Lhe ORIGINAL 





ttgo.u.s.rAT.QfT" 


•ooe PRoc^ 

SURGEONS' '^'S' 


GLOVES 


THE MASSILLON RUBBER CO. 

MASSILLON OHIO 

World's leading manufacturer of surgeons gloves 

(Guaranteed to comply with commercial standard 
spccirications CS 41-32 and CS 40-32) 


CONTENTS — Continued 

The Tfaliffltj’ of Frafiiiienfs of Sfensfriinl Eiiiloiiicfrium. SnnnicI H. GeLsf, 

M.D., IV'enr York, X. Y 7.11 

Plaeeiifa Previa With Twin Prepriinucy. .lanie.s S. Ramlcnlnish. M.D., Plill- 

nilelpliia, Pa - 7S2 

Gauze Pad Uemovcil From the Abdomen. Carey Ctillicrlson, Cliieapro, 

111 732 

Abdominal PreAnaney Compllealed by Eelnmpsia. Edward Allen, 3I.D., 

CbleapTO, 111 733 

A Spceiilum for U.se in Cervleni Canterlzaflon. Edward Francl.'! Mcliausrlilin, 

3I.D., Pliilndeliibin, Pa 753 

A.spcrjrUlu.s Fiimig'ntas Vafrlnifis. Mark T. Goldsllne, 31.11., Cbieas'O, HI 750 

Society Transactions 

Society Trniisactioii.s ToT 

Department of Reviews and Abstracts 

Collective Revien— Acute (Extrapreultnl) Infectious iu Presruaiicy, labor. 


and the Puerperium. J. P. Grecnlilll, 3f,t>., Cbleasro, IU. 7C0 

Selected Abstracts — Eckimpsia 773 

ltcn« — American Board of Obstetrics and Gynccolosy 77S 




ADVERTISEMENTS 


5 



The “D&G” mark is a ' 

suture dependability. 
quarter century of : 

to the highest ; 

DAVIS & ') 5 » 3 ; - ■'••' 

■nfT' ' ' ■ ' ■' ■ ■ - ' - - • 




CONTENTS FOR JUNE, 1933 
Original Communications 

Epitliellnl Proliferation in tlio Cervix Uteri Durinfr Pres-nnney, and Its Clinical 

Implications. .1. Ilofbaner, jM.D., Italtimore, jMd. 779 

The Toxic Psychoses of Pregnancy and the Puerpcrinm. I.eon S. McGoo^ran, 

M.D., Omaha. Neb. 790 

Ktiolocy of Prolapse. lOrwin von Orall, M.J)., Iowa City, Iowa 800 

Avitaminosis as a I.iUely Btiolosie Factor in I’olynearonitis Complieatinfr 
Pregnancy, With the Report of a Case. Ralph Rnikart, SI.D., F.A.C.S. 
Omaha, Neb. 979 

A Consideration of the Schneider Modiflcation of the Aschheini-Zondek Test ns 

Related to Private Practice. Harold S. Morgan, M.D., Uineoln. Neb. 81C 

Trichomonas Vaginalis (Donne) 3. Irving F. Stein, B.S., M.D., and Elizabeth 

.1. Cope, B.S., Chicago, 111. I L 810 

Endometrial Hyperplasia. Encins E. Burch, M.D., and John C. Burch, M D 

Nashville, Tenn. ‘ ^og 

A Naegele Pelvis With Coineidental Deformities of Genital Tract and E.xtrcmi- 
ties. James R, Rcinberger, M.D., Memphis, Tenn. J 


The Test of Labor. Louis Rudolph, M.S., M.D., F.A.C.S., Chicago, III. 

Further Studies In the Treatment of Puerperal Septicemia and Other Blood 
Stream Infections AVlth Metaphen. J. B. Bernstinc M D F A r c 
Philadelphia, Pa. ’ ’ 


834 

840 


849 


( Continued on page 7 ) 


6 


AMEHICAN JOURNAL, OP OBSTETRICS AND OYNECOLOGY 


Caution mothers not to coax, bribe or scold I 


Have them make sure first that the 
chifd's diet furnishes enough of the fac- 
tor essential for appetite—Vitamin B! 


The child who won’t eat may not be as 
great a problem as many mothers think. 
Sometimes the reason for poor appetite 
is a simple fault of diet which can easily 
be corrected. 

All that some children need is more of 
the important factor which stimulates 
appetite. 

Adding a rich source of Vitamin B to 
their regular diet helps to restore normal 
hunger. Mothers are spared a trying scene 
at the table. 

And there’s a simple, effective means 
now of giving children extra Vitamin B. 
A delicious, appetite-building drink 
supplies it—Squibb Chocolate Savored 
Vitavose! 

One glass of milk to which three heap- 
ing teaspoonfuls of Chocolate flavored 
Vitavose have been added contains as 










much of the appetite-stimulating factor 
as a whole quart of milk. 

It also supplies valuable food iron. Pale, 
underweight children who need building 
up benefit particularly. 

Few other food drinks so quickly im- 
prove children’s appetite, color, and weight. 

Have mothers begin to give them Squibb 
Chocolate flavored Vitavose regularly 
every day. Children will enjoy its fine, 
delicious flavor. Mothers may soon remark 
on the improvement in the child! 

A vital need during pregnancy often un- 
filled— The mother may not receive enough 
Vitamin B to ensure a quality of milk 
which satisfies the baby. Physicians are 
advised to recommend a supplement of 
this important factor regularly. Chocolate 
flavored Vitavose, because of its agreeable 
taste and because it is taken with milk, 
has particular advantages for the mother. 
Suggest its use during pregnancy. 


QUIBB /a LHOCOLATE 

ViTaVOSE 


/f delicious blend of sucrose, 30% Vitavose (malted wheat germ extract), cocoa, skim milk, lactose; flavorcdwithyatfilla 



ADVERTISEMENTS 


7 


c 


OPPERIN 




In obstetrics and gyne- ' 

oology a desirable type ^ ^ ^ 

insures its utilization. 
because as a result of this 
more complete utilization, the 
smaller iron dosage is sufficient. 

because Copperin is easy to administer — it is well tolerated, no taste, no odor and the 
dosage can be accurately controlled. 

because Copperin has been sho^vn by clinical tests to produce a prompt improvement in 
the blood picture. 

Use Copperin for anemias of pregnancy, post-partura anemias, post-operative anemias 
and during convalescence. 

Write for literature and samples. Ttvo forms — Copperin "A” for adults, Copperin "B” for 
children. Bottles of 30 six-grain capsules, or the new large economical size 100-capsulc bottle, 

MYRON L. WALKER CO., INC. 

5 0 8 FRANKLIN AVE., MOUNT VERNON, N.Y. 


F 


CONTENTS — Continued 

Itcport of a Cnso of Ablatio tiacontae FoUowetl by Slouching- of fho Dteriis. 

W. A. Coventry, M.D., and KusscU J, Moe, 5I.D., Duluth, Minn. 859 

Congenital Defects of the Scalp, N. William Ingalls, M.D., Cleveland, Ohio 8Cl 

Hysterostoraatoray. Dawrence M. Kandall, M.D., Kochestcr, Minn. 813 


The Pupillary Test for the Diagnosis of Pregnancy. Z. Bcrcovltz, M.D., 

Pyongyang, Chosen. ggn 

The Treatment of Dterine Bleeding tVith Snake A''onom (Ancistrodon Pis- 
civorus). Samuel M. Peck, M.D., and Morris A. Goldborger. M.D.. 
P.A.C.S., New York. N. Y. ___1 I 8 g 7 

Abruptlo Placentae. Isadore A. Siegel,- A.B., M.D., Baltimore, Md. 894 

Retzlus Space Abscess Pollowing Daparotomy. E. Edwin Beeves, M.D., Ama- 
rillo, Texas g 9 .j 

Adenomyoma (Adenomyosis of Frnnld) of the Dtcrus IVith Tuberculous Infec- 
tion. B. H. Bigdon, M.D., Durham, N. C. g 03 

Granuloma of the Vaginal Vault. Nathan P. Scars, Ph.B., M.D., Syracuse, 

N, T. gQQ 

A Modiflcatlon of the Friedman Pregnancy Test. Morton Vesell, M D New 

York, N. Y. ggg 

Pregnancy and Eabor Subsequent to Abruptlo Placentae and Dteroplacontal 

Apoplexy. Samuel S. Boscnfeld, M.D., F.A.C.S., New York. N. Y. Oil 

(Continued on page 8) 



AMEIUCAK JOURNAL OK OBSTETRICS AND GYXECOI.OGY 


s 





A skin texture" treatment 

ON LATEX GLOVES 

At last, the perfect surgeons’ glove! Motex Derma- 
tized glove. Dermotized — it resembles the texture 
of skin. Dermotized — it is slip-proof, o surface with 
a million microscopic vacuum cups, Dermafized — it 
rivals the sensitivity of the bare fingers. Matex 
Dermotized gloves ore so different from anything 
you hove ever used that you must wear and test 
them to realize how perfect they really are. 

Present the Gift Coupon to your 
surgical supply dealer. 

To Any Matex Dealer; 

This coupon entitles cuslomor fo ono Tree poir of Motex 
Dermotized Gloves with the purchase of one or more pairs of 
Motex Dermotized or Motex Smooth Gloves. 

Dealer's Name. Size 

Add ress 



CONTENTS— Continued 


Report of a Case of Kiipliireil Ovarian Cyst in llie Newborn. Samuel 31. 

Doilck, M.D., 31.A., IVasliliiKton, I). C. OH 

The Treatment of Asphyxia In the Newborn by I.iinir Intiafor for Indirect 

Moufh-to-3Ioufh Itreatliins:. I’ieree JlacKenzie. SI.D., Uvansville. Iml. — 918 

True Sarcomatous CIiauKc in a Uterine Kibroiil. raiil 1). Scofield, JI.D., 

Columbus, Ohio 920 

A Simple Procedure of Ascertalninp- the Sex of the Newborn, IVhere the Dinsr- 
nosis is Difllciilt Due to Genital Abnormalities. ,1. Thornwell IVither- 
spoon, M.A., Oxon., SI.D., New Orleans, I.n, 921 

The Umbilical Cord Relatively Shortened by Coilinp About the Neele of the 

Fetus. Abner Zehm, 31. D., Schofield IJnrrncUs, T. II. 92.8 

Incomplete Bipartite Uterus With Unilateral Ilematocolpos and Salpinsritis. 

Georpe I.. Carrinfrton, A. 31., 3I.D., Itiirlijifrton, N. C. 921 


Society Transactions 

Central Association oC Obstetricians and GynecoIopivSts 02G 


Index 


92- 


Index 




American Journal of 
Obstetrics and Gynecology 

VoL. XXV St. Louis, Januaky, 1933 No. 1 


Original Communications 


THE COMPLICATIONS OP RADIUM THERAPY IN 
OYNECOLOGY® 

George Gray Ward, M.D., F.A.C.S., New York, N. Y. 

(From the Clinic of the IFoman’s Hospital) 


T hat facilities to treat cancer patients must lie established in our 
general hospitals throughout the countiy as well as in the large 
special institutions such as the great cancer clinics of Stoelcholm, Paris, 
Munich, and New York, is inevitable, because the patients suffering from 
cancer are alreadj' far too numei’ous for these centers to take care of 
and the disease is steadily increasing. 

This means the staff of the general hospital must be educated to a 
proper appreciation of the complexities of this disease, and must be 
trained in the most approved technic of radium therapy as well as 
surgery, for without this agent available no hospital today can be con- 
sidered properly equipped. 

On superficial thought the acquiring of this knowledge and technic of 
radium therapy seems a comparatively easy matter as the application of 
the element appears so simple. The alluring advertisements of the com- 
mercial agencies who rent radium, urging the general practitioner to 
send a description of the ease, and they will forward directions with the 
proper dosage of radium, apparently confirms the prevailing impression 
that any one can apply it without special knowledge or skill. 

Let me emphasize the warning of Madame Curie on her last visit to 
this country when she called attention to the great dangers of the im- 
proper use of radium. As Regaud, of the Paris Clinic, has recently said, 
“ It is necessary to have much experience to obtain from this method of 
treatment all the good that it may give without the evil that it may do. ’ ’ 
“Correspondence Courses” in radium therapy are dangerous for the 


‘Read at a meeting of the Brooklyn Gynecological Society, May 6, 1932. 


Note: The Editor accepts no responsibility for the views and statements of 
as published in their "'Original Communications." 


authors 


1 



2 


A5IERICAN JOURNAL, OF OUSTETRICS AND GYNECOT.OGY 


inexperienced. While the renting of radium from these agencies is of 
course perfectly Justifiahle, the knowledge and judgment as to how and 
when to use it can only he bought, by careful study and personal ex- 
perience and observation in radiologic clinics. Indeed radium is a two 
edged sword, and its use is far from .simple. 

To appreciate this we must fii-st have some knowledge of the action of 
radium on the tissues, lladium does not remove a cancerous growth by 
dc.sti*uction of the entire part affected as is accomplished by surgery or 
cautery, but the gamma rays have a direct selective action on the cancer 
cells, destroying them without injuring the normal cells at the site of 
the neoplasm. 

This is demonstrated in healed cases of carcinoma of the cervix, where 
the normal shape of that organ may be restored vuth no trace of the site 
of the gi'ouTh. 

Another action of radium is to cause the proliferation of connective 
tissue. The connective tissue contracts, with the resulting obliteration 
in great degi'ec of the blood and lymph supply, producing the contracted, 
pale looking cervix and funnel shaped vaginal vault, that we see in the 
ideally healed cases. 

If the do.sagc suitable for a certain case is used, we will destroy the 
cancer cells but noi the normal tissues, owing to the selective action of 
the gamma rays on the carcinoma, and the greater resistance or toleration 
of the normal tis.sues. 

If we give much larger doses of radium than is required to destroy the 
cancer cells, we will also destroy the normal structures and produce 
extensive necrosis with its residting septic absorption, hemorrhages, and 
injuiy of adjacent viscera, with pei'haps the pi-oduction of fistulas. 

Remember also that these unfortunate results of overradiation with 
this powerful element are commonly attributed to the extension of the 
carcinoma, or frequently the action of the radium is blamed and conse- 
quently condemned as of no value. 

We must see also that if too small an amount of radium is used, or for 
too short a time, that we may fail to destroy all the cancerous tissue. 

Upon the proper screening of the radium depends the elimination of 
the beta, or burning rays, which cause extensive destruction of the normal 
tissue. Various metal containers of different thickness are used such as 
platinum, gold, silver, or brass for this purpose, and damage of the blad- 
der and reetum is avoided by “distance screening,” that is pushing them 
out of reach of the rays bj^ overdistending the vagina with gauze. If 
inadequate screening has been used, unnecessary necrosis will result. 

Too frequently repeated radiations, especially if a heavy dosage for 
prolonged periods is employed, will result in the so-called “late reaction” 
of radium. Six months, or a year or more, following the initial treat- 
ment dense infiltration, pelvic pain, ulceration, and discharge may de- 
velop, which is apt to be attributed to a recurrence of the disease, when 



WARD; RADUTSI THERAPY IN GYNECOLOGY 


3 


actually it is the result of aii overirradiation of the tissues with a result- 
ing excess of connective tissue formation. This produces a slowly de- 
veloping obliteration arteritis, and the devitalized structures ulcerate 
and become a ready prey to infection. 

From this brief summary of the action of radium on the tissues and 
the damage that it may cause by a defective technic, it should be ap- 
preciated that safety in its use depends on the careful study of the loca- 
tion and extent of the disease, of the type of cell and the degree of its 
maturity, of the general physical state of the patient as to age, hlood 
condition, and toxemia, of the carc/«l preoperative preparation of the 
patient, of the amount of radium used and its distribution in appropriate 
containers, on the proper emploxyment of screening to exit out the burning 
rays, on the placing and maintaining of the x'adium in situ where it will 
destroy the cancer and j'et not damage adjacent viscera, on the duration 
of the application, and the time and dosage of reradiations and deep 
x-ray therapy, and finally on a carefxd freqxicxit folloxv-xip. 

A personal experience in studying the action of radium on this disease 
over considerable periods of time is essential before one can become 
competent to properly treat cancer of the uterus with radiotherapy. 

The complications that we may encounter in radiotherapy of the 
uterus are many. Some of them we cannot avoid, but the incidence can 
be materially reduced by following the accepted technic of those ex- 
perienced in its use. 

It is of interest to note that in the enormous mass of literature that 
has been published on radium therapy, while the complications are men- 
tioned, it is rare to find a detailed analysis of the subject. 

Very little has been written regarding the frequency of postradiation 
symptoms, yet as they are encountered in all clinics, varjdng from mild 
temporary discomforts to severe and most distressing complications, in- 
volving prolonged suffering and even death, it would seem of value to 
study this phase of radium therapy in the hope of reducing their 
incidence. 

We have recently had an analysis made of 558 cases of carcinoma of 
the cervix in our clinic, and there were 119 who had some form of post- 
radiation morbidity, or 21.3 per cent. 

In 106 cases of carcinoma of the fundus, of which 88 were treated by 
radium, 11.4 per cent had complications. 

This study shows that there has been a gradual decline in the fre- 
quency of complications in the latter years in this series. This is prob- 
ably due to the more meticulous attention paid to the details of the 
technic and to an improvement in judgment as a result of our experience. 

The primary mortality from radium therapy in carcinoma of the 
cervix should not exceed 2 per cent. It should be nil in the early eases 
(Class I and Class II). In oui’ last published series it was 1.1 per cent 
with none for the Class I and II eases. This mortality is nearly always 



4 


Ai^IERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


due to the unwise emplo^Tnent of radium in cases witli extensive disease 
in which an acute sepsis is present or results. 

When the destroyed carcinomatous tissue sloughs away as a result 
of the action of the radium, a certain amount of bleeding (secondary 
hemorrhage) will occur in some eases, which varies in amount from a 
moderate oozing to a severe hemorrhage in those cases where the disease 
has encroached upon the blood vessels, and may require prompt packing. 

In our series we have had some bleeding in about 10 per cent, but very 
few were of the severe tj’pc. 

Vesical irritability and rectal irritability os a result of the action of 
the rays on the bladder and rectum is mentioned as a frequent complica- 
tion by many clinics. 

In our hands we have had comparatively few cases where this has been 
troublesome, appx’oximately 4.5 per cent. 

We believe that this is duo to the meticulous care we use in distending 
the vagina to the utmost with gaxize packing, thus getting the maximum 
value of "distance screening.” 

As we have observed the teehnie in some clinics this extreme distention 
of the vagina is not always done. 

We believe also that the use of a .self retaining catheter in the bladder 
while the radium is in place, helps by keeping the bladder collapsed, as 
the full bladder lies close to the anterior uterine wall and the radium 
in the uterine cavity, which has a ^penetration of about 3.5 cm., can 
easily reach the bladder. 

Eadiation cystitis is manifested by frequenc.y and dysuria, and may 
be very troublesome and last for a long time, as ulcerations may result. 

Proctitis is exddenced by diai'rhea, rectal pain and ulcerations. Our 
incidence was 3.1 per cent. Most writers speak of this as a more trouble- 
some complication than cystitis. 

These ulcerations of the bladder and rectum are often mistaken for 
an extension of the carcinoma. 

Vesicovaginal fistula is one of the most distressing complications that 
we meet in radium therapy. It is frequently difficult to tell whether the 
fistula is a result of the extension of the disease or of the radiation. 
Should the disease invade the anterior vaginal wall, there is great danger 
that a fistula may be produced if the dosage is too large. 

Judgment as to the proper dose must be based on the thielmess of the 
septum and upon experience. 

I believe one of the most dangerous conditions we have to deal with is 
in those eases where a previous supravaginal hysterectomy has been done 
and cancer has developed in the cervical stump. 

The bladder then lies on top of the cervix at the site of the amputa- 
tion where it will come in direct contact with the radium fribe placed in 
the cervical canal. 

We have seen 40 eases of cervical carcinoma which had had a previous 



WARD; RADIUM THERAPY IN GYNECOLOGY 


hysterectomy in our series of 558 cases, or 7.2 per cent. Some of these 
developed a fistula, whether from the radiation or the disease we are 
not sure. In these patients the incidence of hemorrhage was increased 
one and one-half times, and of fistula two and one-half times, so in recent 
years it has been mj’’ practice to reduce the radiation one-half in these 
cases, repeating as necessary. 

Vesicovaginal fistulas do not tend to heal of themselves. In two in- 
stances I have successfully closed these postradiation fistulas by 
operation. 

Case 1. — Miss M. J., aged thirty, came under my observation in February, 1927, 
with carcinoma of cervix Class III, squamous cell Group I. She was given 4200 mg. 
hours. She had considerable slough and did not respond well, became cachectic, lost 
weight and developed a vesicovaginal fistula in the anterior vaginal vault 2 cm. in 
diameter. She entered the House of Calvary as a hopeless case, but to our astonish- 
ment returned to our follow-up clinic in December, 1927, wdth no evidence of the 
disease and feeling perfectly well except for the fistula. I successfully operated upon 
her in February, 1928, and she has remained in excellent health to date. 

Case 2. — Mrs. M. S., aged forty-three, had had an amputation of the cervix fol- 
lowed by radium therapy for carcinoma in a neighboring city in November, 1927. 
She came to the Woman’s Hospital in January, 1929, suffering from a vesicovaginal 
fistula in the vault and dense infiltration of the entire anterior vaginal w'all and a 
severe cystitis. She was thought to have a metastatic invasion of the bladder and 
seemed a hopeless case. On passing a sound into the bladder, a click demonstrated 
the presence of a large calculus which was firmly imbedded in the trigone and which 
gave the impression of a dense infiltration. I did a cystotomy from above, removed 
the stone and drained; the bladder promptly cleared up, and she rapidly recovered 
with no evidence of carcinoma. The fistula I attempted to close in May, 1930, but 
failed. It was an exceedingly difficult case owing to a small contracted vagina and 
dense scar tissue forming the margins of the fistula. I tried again in February, 1931, 
with the same result. In December, 1931, a third attempt was perfectly successful. 
I succeeded this time because I first dissected out the entire funnel shaped vault of 
postradiation scar tissue, in the apex of which was the fistula. 

Eectovaginal fistulas sometimes heal of themselves, but the most 
troublesome eases are those which develop an ileovaginal fistula. On ac- 
count of the liquid state of the stools, which are intensely irritating, these 
patients suffer excruciatingly. This complication may be caused by a 
loop of the small intestine being adherent in the culdesac or to the pos- 
terior surface of the uterus, and excessive radiation or the extension of 
the disease results in the fistula. We had such a case due to the exten- 
sion of the disease as proved by autopsy, in which three loops of small 
intestine were adherent to the back of the uterus and culdesac. 

The most unusual ease of rectovaginal fistula Ave have encountered was 
as follows : 

Mrs. E. O., aged twenty-seven, came to the clinic in July, 1926, with a caicinoma 
of the cervix Class III, Group I. She was radiated but did not respond well, and as 
she seemed in a hopeless condition entered the House of Calvary in January, 1927. 
She returned to us in September, 1927, apparently free from carcinoma. In Feb- 
ruary, 1930, she developed a pelvic abscess which resulted in a fecal fistula between 
the upper sigmoid and the vaginal vault. The fistula, however, was small and did 



6 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


not trouble her greatly unless her bowels were loose. In Pebrnary, 1032, she de- 
veloped an acute cellulitis over the center of the posterior surface of the sacrum 
which we felt certain was due to bony metastasis, although the x-rays were negative. 
On Jlarch 8, 1932, I opened this abscess and the next day a fecal discharge was in 
evidence. X-ray studies showed that this sinus ran through the sacrosciatic notch 
to the original fistula wliieh thus discharged through the vagina and through the 
back over the sacrum. On March 29, 1932, I made a temporary colostomy and the 
sacral sinus has closed and the vagiiml sinus nearly so. There is no evidence of 
carcinoma to be determined and she seems perfectly well nearly si.x years after her 
original radiation. It is our intention to close the colostomy should the vaginal fistula 
heal. 

There were 22 cases of fistulas in our series of 558 cases, or 4 per cent. 
What proportion were due to the radiation and what to the disease it is 
not possible for us to determine. 

We believe that cases having a history of previous pelvic inflamma- 
tory disease with or without operation are liable to intestinal fistula as a 
complication of the ti’catmcnt or the disease on account of the proximity 
of an adherent loop of bowel to the site of the disease. 

As a rcisult of the contraction which follows radiation, due to forma- 
tion of dense conneetivc tissue, the cervical canal may be partially or 
completely occluded. An infection of tlic endometrium of the uterine 
cavity frequently results, and a condition of pyometra develops with or 
without retention. Cramplike pains due to uterine contractions and en- 
largement and softening of tlie fundu.s arc suggestive signs. 

A monthly follow-up of all cancer cases such as Ave have at the 
AVoman’s Hospital enables one to discover this complication in its in- 
eipieney, and the passage of a sound makes the diagnosis and corrects 
the condition. 

Pyometra was a complication in 3.6 per cent of our series. 

The primary mortality in radium therapy is almost always due to 
the lighting up of a septic infection which x'esiilts in peritonitis. The 
cai’einomatous cervix ivith its sloughing and ulcerated surface is likely 
to harbor pathogenic bacteria. Preliminary vaginal antiseptic douching 
should be emploj’^ed. Trauma in dilating the cervix and placing the 
radium should be avoided. A biopsy is safest when done with the radio 
knife. Tlie presence of a temperature and signs of pelvic inflammatory 
disease should indicate rest in bed for a few days as a preliminary 
measure. 

Anemia and asthenia should be combated with a blood transfusion 
prior to the radiation. 

A temperature reaction up to 101° may be considered as normal im- 
mediately following the application of radium, but it should promptly 
subside. High temperature after radium tlierapy Avas formerly at- 
tributed to the absorption of toxic substances from the disintegrating 
tumor, but it is now known to be from infection. AVe are inclined to 
believe that the high incidence of sepsis following radiations in some 
clinics may be due to the daily and repeated intrauterine applications. 



WARD; RADIUM TUERAPY IN GYNECOLOGY 


7 


In onr clinic the incidence of sepsis as indicated by a temperature of 
102° or more is but 2.7 per cent. 

The contraindications to radium therapy are few, except in eases 
with an active septic infection and peritonitis, and in advanced Class IV 
eases with frozen pelvis. 

Sloughing ulcer from over irradiation and insufficient screening, 
which means destruction of normal tissues as well as the carcinoma, 
should be preventable. 

Late reactions coming on six months or a year after the initial treat- 
ment and which are frequently mistaken for a recurrence of the disease 
are likewise usually due to over radiation. 

Eadium burns in normal tissue from displacement of the radium is 
apt to occur if the applicators are not anchored in place. We believe 
this is an important point in the technic of application as shown in the 
following ease : 

Mrs. S. had had radium and x-ray therapy for nonmalignant metrorrhagia. She 
came to mo three months later suffering excruciating pain in her vagina and a foul 
discharge. Examination disclosed a sloughing ulcer in the riglit lateral vaginal 
fornix the size of a quarter -with acute vaginitis and infiltration. The possibility of 
malignancy was considered but a biopsy proved there was no malignancy. The 
ulcer was evidently due to a radium burn from the applicator becoming displaced 
alongside the cervix. After five mouths of suffering the ulcer entirely healed with 
complete relief from pain. 

Nausea and vomiting occasionally occurs while the radium is in place 
but was noted in less than 1 per cent of our cases. 

The contraction of connective tissue formation in the broad ligaments 
is a late complication and may produce an obstructed ureter and involve- 
ment of the kidney. Severe deep seated pelvic pain, if not due to the 
disease, is probably the result of connective tissue contraction. Stric- 
ture of the urethra also has been observed. 

Phlebitis involving the leg may occur. We encountered it in 0.54 per 
cent. 

In the 106 cases of carcinoma of the fundus we have encountered, 88 
were treated by radium therapy, either alone or in combination with 
surgery. We prefer to give an intrauterine application of radimn at the 
time of the diagnostic curettage in these eases followed by a pan- 
hysterectomy four weeks later. In about 50 per cent of these patients 
we have been compelled to use radiotherapy alone because they were 
poor operative risks. These fundus eases were less apt to have com- 
plications than the cervix cases, as there were twice as many complica- 
tions in the latter. It is noteworthy that postradiation hemorrhage did 
not occur at all in the fundus cases, while pyometra was more frequent, 
being met with in 4.6 per cent as compared to 3.6 per cent in cervix 
carcinoma. 

As we would expect, proctitis is one-third less frequent than in the 
cervix patient. 



8 


A3IERICAN JOURNAL. OP OBSTETRICS AND GYNECOLOGY 


One of the most distressing complications we can encounter from 
radium tlierapy is when it is used to check a menorrhagia in a young 
woman and an overdose is given. 

In such intractable bleeding cases which do not yield to cui’ettage or 
hormone therapy success may be achieved with a very small dose of 
radium, 200 to 400 mg. hours. If we approaeh 600 rag. hours we are in 
danger of causing a permanent amenorrhea and atrophy. 

It is far better to underradiate these cases with the understanding 
that the treatment may have to be repeated, than to give too much. 

Mis.s V. I?., nged twenty-tive, nnd socially prominent, was brought to me by her 
mother for an amenorrhea of one year’s duration and menopause symptoms follow- 
ing ail intrauterine application of radium for a persistent menorrhagia which had not 
been relieved by repeated curettage. The examination disclosed an atrophic uterus 
with a contracted canal. On inquiry, her physician stated to me that he had called 
in a radiologist who had given the patient a dosage of 1440 mg. hours. She was of 
course beyond relief, and as she wished to got married the family were greatly 
distressed. 


I know of a similar instance of an inexcusable over dosage in a young 
girl. 


CONCLUSIONS 


Since 1919 to date we have had in our cancer clinic some 560 eases of 
carcinoma of the cervix and 106 cases of fundus carcinoma. 

A study of these cases shows that approximately 19 per cent have had 
some form of complication, although the large majority have been of a 
minor and transitory tjiie. 

We cannot always avoid some of these complications as they occur in 
the most expcx’ienced hands, but they can be materially reduced in num- 
hei’, if the action of radium on the tissues is understood and meticulous 
care is taken in following the essential details of the preliminary treat- 
ment and technic of application. 

It is just as necessary that men should be properly trained in the treat- 
ment of cancer of tlie uterus by radium therapy, if satisfactory results 
are to be obtained, as that they should be properly trained in surgery. 

As Lord Mojmilian has stated, “The surgeon’s Imife in most highly 
trained hands is an instniment of great delicacy, but it cannot always 
discriminate between healthy and diseased tissues. Radium is an in- 
strument of far greater delicacy because its action is selective, that is to 
say, it acts differently upon diseased and healthy tissues, killing one 
and leaving the other.” 

Finally I desire to emphasize the fact that the safe employment of 
X'adium requires experienced piloting as we are litei’allj’^ sailing between 
Seylla and Charybdis in attempting to avoid the damage we may inflict 
by overradiatioii on the one hand and the failure to destroy the disease 
by insufficient radiation on the other. 

48 East Fifty-Second Street. 



WAED; RADIUIiI THERAPY IN GYNECOLOGY 


9 


DISCUSSION 

DE. HARVEY B. MATTHEW S— Complications, both severe and mild, are knovm 
to follow the use of radium, but very few of us have taken the trouble to tabulate 
our cases as Dr. Ward has done in an effort to ascertain the complications that 
actually occur. Dr. Ward has tabulated every complication except perhaps one, a 
severe vaginitis, very intractable, causing considerable disability, but after a long 
period of treatment, finally healing. 

The late complications including the indurated cicatricial scars in the broad liga- 
ments, are not always due to irradiation, but are aggravated b}’ it and become more 
solidified, almost cartilaginous in character. It is no wonder that they produce 
very severe, disintegrating, continuous pain. If the ureter is in the scar, then we 
have superimposed the symptoms caused by this complication. 

Dr. Ward did well to insist that this work needs special training. Experience 
is required not only in the treatment of the cervical and body cancer cases, but 
the nonmalignant uterine bleedings as well. 

DR. WILLIAM SIDNEY SkllTH. — ^We use radium at the Brooklyn Hospital 
very similarly to the manner in which Dr. Ward uses it. Our service is small. I 
would like to urge the value of heavily screened radium and that you are much less 
likely to get into difficulties than if you use radium screened so that the Beta rays 
get through. We use radium screened with a full millimeter of platinum and have 
had but few bladder complications (cystitis, etc.) and very few rectal complications, 
than elsewhere, because in early carcinoma of the cervix we almost always use it in 
conjunction with cautery. If the case is early, and the cervix can be pulled down, 
we do a Byrne cautery operation and then put the radium in the cavity. If the 
case is farther advanced, with some induration, and the cervix will not come down, 
we often sear off the sloughing mass with the cautery and then insert tlie radium, 
either in the form of a T with one capsule within the remainder of the cervix and 
the other crosswise against it, or we use both capsules in parallel right up against 
the cervix. It is interesting to note that our only bladder fistulas have followed 
operations in which the cautery was used. In one case in which a Byrne cautery 
operation was done radium was inserted for 2,400 hours, the patient was sent for 
x-ray and she was given heavy x-ray dosage which, by the way, caused a great deal 
of shock. In tAvo months we gave her another dose of radium (2,400 hours) and the 
x-ray was again tried, but the shock was so great she was only given one dose. That 
was nine years ago. She is still alive, but has had a bladder fistula for five years. 
There is a great deal of induration in her pelvis and very little mobility. I have 
advised her against trying to have the fistula repaired because I think it might light 
up her carcinoma. She gets along fairly well with it. 

The other fistula occurred after a cautery amputation of a carcinoma of the cervix 
with the radium laid against it. Her carcinoma seemed to be fairly well healed for 
a time, then the fistula developed. It was closed by operation for about six months, 
and then broke down, the carcinoma lighted up, and she finally died. 

DR. DAVID EEINER. — 'The mischief that can folloAV the improper introduction 
of radium, is shown by a case of a woman who was in labor at home for about 
twelve hours under the care of a midwife. Wlien brought in the cervix was three 
fingers’ dilated, the cord prolapsed and a foot protruded. A physician was called in 
who did not recognize the pathology that was present and tried to do an extraction. 
The patient was about seven months pregnant. He thought the child was under- 
sized and would come out without much difSeulty. He desisted after he had removed 
the body up to the neck, and the latter snapped, with the head remaining inside. I 
then saw the patient and found a dense cicatricial stenosis of the cervix with marked 
fibrous replacement of the entire vault of the vagina. The head was oversized, ap- 



10 


AMERICAN JOURNAL OE OBSTETRICS AND GYNECOLOGY 


parcntly hydrocephalic. We tried to incise the cervix and made very little progress 
because of the severe bleeding. Wc finally did a lap.arotomy and removed the uterus 
with the contained head. On subsequent inspection of the uterus and microscopic 
examination of the sections of the lower .segment the cervical portion showed extensive 
fibrous replacement of tiie muscle tissue and undoubtedly in this case in which 
radium had been used, the cavity of the uterus was not packed to keep the tube up 
near tbo fundus u’here it belonged, but mis allowed to prolapse do^v^ to the cervical 
canal and brought about cicatrisation and stenosis. 

Dlt. GEORGE G. WARD. — Vaginitis ma)- occur, although wc have h.ad very little 
dilTiculty with that complication. In one instance there was definite sloughing of 
tho vaginal mucosa which caused a good deal of trouble. I have always felt that 
the marked distention of tho vagina with gauze was a preventive. 

As for involvement of the bladder, it is not uncommon in our cxiierienee when we 
send a case to tho urologic department to have a report that there is metastasis in 
that org.an. In quite a number of instances this has proved not to be the case, 
but n bullous edema and possible ulceration was there, due, undoubtedly, to the 
radiation. Those cases have in a number of instances entirely cleared up although 
they have a prolonged convalescence. We must not immediately .I'ump to the con- 
clusion that it is carcinoma of the bladder, and must remember that it m.ay be due 
to tho radium. 

For ii long time I fc.arcd that tho repair of a postradiation fistula might light up 
latent cancer cells imprisoned in tho connective tissue. Our pathologist examined all 
tissue removed in cases of vesicovaginal fistula and in no case were carcinoma cells 
found in the cicatricial tissue around tho fistula. 

Tho difficulty of removing radium is an important matter and that is why we 
have developed the particular technic employed. Tho displacement of a tube of 
rndhim from the canal is duo to the contraction of the uterus. That is why we 
anchor the radium in place. 


THE TECHNIC OP RADIATION THERAPY IN UTERINE 

CARCINOMAS'' 

Henry Schmitz, A.M., M.D., P.A.C.S., P.A.C.R., Chicago, III. 

T he criteria of an adequate radiation tissue dose delivered into a deep 
seated or internal carcinoma are a rapid resolution of the grovrth, a 
restoration of the surface epithelium and a limited fibrosis. The prede- 
termined radiation tissue dose evidently should be uniformly or homo- 
geneously distributed throughout the cancer beai’ing area. The radiation 
dose should be lethal to the carcinoma cells and should not cause ir- 
reparable injury to the normal tissue lying within the radiation field. 

The good end-results depend not only on an adequate, homogeneous 
radiation tissue dose but also on the location of the gro^vth, on the clin- 
ical extent of the tumor, the degree or grade of histologic malignancy, 
the presence of complicating infections and the general constitutional 
state of the patient as determined by age, cachexia, toxemia, complicat- 
ing diseases, etc. These factors are only mentioned since the following 
discussion is limited to the technic of radiation therapy. 

*Reacl at a meeting of the Chicago Gynecological Society, February IS, 19S2. 



SCHMITZ; TECHNIC OP RADIATION THERAPY 


11 


Tlie lethal radiation tissue dose for sarcomas and carcinomas has been 
tentatively placed by Wood and Prime" at about 4.5 to 7 erythema doses 
of filtered roentgen rays or gamma rays applied to the tumor. The 
tumor should be rapicllj'- growing, very cellular and highly malignant. 
These are characteristics associated wdth a high degree of radiation 
sensibility. Wood- further states that the production of absolute perma- 
nence of cure by radiation therapy implies that the destruction of the 
tumor cells must be as complete as must be their removal for effective 
surgery. These findings have been eorrobox*ated bj’' clinical experiences 
as reported by Quick, ^ Lee,^ Pfahler,® Schmitz,® and others. 

The radiation tissue dose for highlj^ cellular and highly anaplastic 
undifferentiated carcinomas of the uteims is probably 4 to 5 erythema 
doses according to our observations. It is necessary to apply this in- 
tensity uniformly throughout the true pelvic cavity. The methods em- 
ployed to accomplish this will be described in the following discussion. 

PHYSICAL PRINCIPLES OP DEEP IRRADIATION THERAPY 

The physical principles of the production of x-rays and radium must 
be known in order to obtain the best results in the treatment of malig- 
nant diseases by radiation. It was deemed desirable therefore to discuss 
some facts of a rather technical nature such as the methods of applica- 
tion of radiations, the relation of the time duration of radiation to. the 
total dose, the factors to be observed and to be recorded on the treat- 
ment charts, and the definitions of the erythema dose, designated E. D. 
and of the international roentgen dose unit designated “r.” 

Radiations may be applied cavitarily, interstitially or distantly. The 
insertion of radium into the cervical canal or the uterine cavity is a 
cavitary application. The introduction of the needles containing radium 
or radon into the tumor, as in the pallisading of the cervix or para- 
cervical tissue, is an interstitial method. The application of roentgen 
rays or of radium contained in a so-called cannon is a distant method. 

The time duration within which a complete radiation series is given 
may varj^ The application of the full dose may be done within the 
shortest possible space of time. This single “massive intensive” method 
is advocated for roentgen rays by Kroenig and aauss," and Seitz and 
Wintz,® and for radium by Kelly and Burnam,® Healy"® and others. The 
tolerance tissue dose, that is the highest dose tolerated by normal tissues 
without serious primary injuries is applied in a single continuous sitting, 
the dose being about 250 per cent E. D. Additional radiations are not 
advisable. If reradiation is necessary then a decreased dose may be ap- 
plied six to twelve weeks later. It is a well established axiom that the 
first course of radiation treatment should be applied in such adequate 
doses that the growth will be arrested, since radiations added at a later 
time are as a rule ineffective. 

An erythema dose may be given at once and followed by the additions 
of smaller doses at stated intervals of three to seven days until a total 



12 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGT 


dose of 2 to 2.5 E. D. lias been attained. In tliis way tbe radiation ef- 
fect is maintained at full saturation. It is known that the loss of radia- 
tion effect of the short wave radiations used in deep cancers amounts to 
4 per cent daily; hence 12 per cent of an erythema dose may be added 
every third day, or 25 per cent of an erythema dose everj’^ seven days 
until a total dose of 2 to 2.5 E. D. has been given. The “saturation” 
method was introduced bj- Pfaliler” wlio based the observation on earlier 
data of Kingery. 

A fraction of a dose, for instance, 40 per cent of an erythema dose 
may be applied every third day 5 times, or 30 per cent of an erythema 
dose may be given every third day 10 times. In other words the frac~ 
tional dose is scattered over fifteen to thirty days. The scattered fraction 
method lias been employed in our clinic for the last twelve years. In 
Europe it is known as the Coutard protracted fractional method. 

In the Coutard method small ampcx'c loads are used so the single 
treatment is applied within an hour, i. e., it is proti'aetcd. We use loads 
of 25 to 30 milliamperes and the application of each fractionated dose 
lasts from ten to fifteen minutes depending on size of filter and focus 
skin distance. 

The advantages of the scattered fraction method are: (1) Large total 
doses can be applied without permanent injury to the normal struc- 
tures. The total dose may be from two to three erythema doses. (2) 
The cancer cell is hit by the rays during the most radiosensitive stage 
which is the time of mitoses occurring in highly undifferentiated em- 
bryonal cells about every six hours and in more mature cells about every 
twelve days. This is also known as the kai'yokinetie index of Proust and 
de Nabias which is based on the ratio of the number of mitotic to the 
number of resting cells. The lower the index the lower is the radio- 
sensitiveness of tumors and the more protracted the treatment should be. 
If the ratio is 1 mitosis to 50 to 100 resting cells then the treatment 
should last six days. Should the ratio be 1 :100 to 1 ;150 the ti'eatment 
should be extended to fourteen days; and should the ratio be 1:150 
or less, then the treatment should last for twenty-five to thirty days. 
(3) Normal tissues react with a mild fibrosis, a desirable attainment as 
it means the production of a defensive and phagocytic tissue. 

A radiation dose is the product of intensity and time. In order to 
correctly describe a radiation technic it is necessary to state the factors 
used in the application. They are: (1) location of tumor; (2) size of 
tumor; (3) depth of tumor; (4) sti’ength of radioactive source; (5) dis- 
tribution of radioactive source; (6) filti*ation; (7) distance or spacing; 
and (8) duration of application. To determine the location, the size and 
the depth of a tumor a caliper and a modified pelvimeter are used. The 
outline and the circumference of the body are drawn on tracing linen 
and the size and depth of the tumor from the anterior abdominal wall as 
measured with the pelvimeter are entei’ed (see Pig. 1). 



SCHMITZ: TECHNIC OP RADIATION THERAPY 


13 


The strength of the radioactive source should he stated in milligram 
radium element hours or in millicurie radon hours with allowance for 
decay. The distribution of the radioactive source should describe the 
construction, the shape and the dimensions of tlie applicator as tube or 
plaque used for the application. The effective length of distribution of 
the radioactive material in tubes or needles should be given. The filtra- 
tion should designate all of the materials interposed between the radio- 
active substance and the tumor including kind and thiclmess of the 
metal, rubber, leather or paraffin filters and the approximate thickness 
of the tissues from the surface to the tumor. 

Distance is one of the most important factors in radiation therapy. 
It should be measured from the center of the source to the surface of the 
tissue or skin. In interstitial radiation it is important to state the spac- 
ing. Hence the number of needles or implants, the strength of each, the 



Fig. 1. — Caliper to obtain the outline of the pelvis. Location of the uterus is de- 
termined by a modified pelvimeter, one arm being straight and flexible to obtain deptlis 
and direction of uterine canal. 

length of active surface, and the thickness and kind of metal container 
should be recorded. If cross firing be used then the location, the size 
of the fields and the focus skin distance should be recorded by means of 
a diagram. Lastly the duration of each seance with the interval be- 
tween each should be given and each recorded separately. The total 
dosage of gamma rays may be expressed in milligram element hours if 
all the factors are otherwise given. 

The factors in roentgen ray therapy include the source and type of 
generator and tube, the wave length, the kilovoltage, the milliamperage 
the size and location of fields, filtration, the focus skin distance and the 
duration and date of each treatment. 

The total dose should be expressed in values of E. D. or “r” units and 
the time Avithin which it is applied should be stated. If the x-rays are 
used, the quality of radiation as determined by the wave length should 
be recorded. It is not necessary to specify the wave length of radium as 
this IS constant and equals a minimum wave length of 0.011 A U or 


14 


AJtEniCAN JOURNAL OF OBSTOTRICS AND GYNECOLOGY 


1128 Iv. V. according to Tliibaud, and an eflcctive wave length of 
0.022 A. U. or 600 K. V. 

The tlu'esliold erythema dose i.s defined as the amount of radiation 
which, if delivered in one sitting, Avill in 80 per cent of the eases treated 
produce a faint bronzing or reddening of the skin and in the other 20 
per cent of the cases will produce no visible effect.' ' The eiythema dose 
therefore is based on a biologic reaction namely the bronzing or i*edclen- 
ing of the squamous cell epithelium of the slcin. 

The international roentgen unit “r” is the quantity of roentgen radia- 
tion wliich when the secondary electrons are fully utilized and the wall 
effect of the chamber is avoided produces in 1 e.c. of atmospheric air at 
0'^ C. and 76 cm. mercury prcssui'c, such a degree of conductivity that 
one electrostatic unit of eliarge is measured at saturation current.'® It 
is purely a physical measurement. However, E. D. may be expressed in 
terms of r. One E. D. i.s 600 r Jneasured on the body surface. The tol- 
erance B. D. means tlie highest dose that may be applied to the skin in 
one sitting and is about 250 per cent higher than a threshold E. D. 



Fig. 2. — Spectrogrupliic men.surements of x-rays produced %vith the factors 200 K. V. 
and 0.75 mm. copper and 1.0 mm. aluminum filter. Shortest wave length is O.OCT A. U. : 
longest wave length 0.27 A. U. ; average wave length 0.15 A. U. 


Dosimeters standardized in r are used to determine the output of 
x-rays from a tube so that the time duration can be calculated within 
which a known amount of r may be applied. 

The scattered fraction method which has been used in our clinic for 
about twelve jmars permits the application of doses that could not be 
made with any other technic. If one uses 200 kilovolts, a focus skin dis- 
tance of 65 to 80 cm., a filter of 0.1 mm. copper plus 0.1 mm. aluminum, 
and a field size of 300 to 420 era." then one may apply a roentgen dose 
of 240 r every tliird day for 5 times, i. e. a total dose of 2.0 E. D. or 
1200 r given within fifteen to eighteen days. If applied in ISO r doses 
then 10 times 180 r maj’’ be given udthin twenty-seven days. The skin 
will show an intense ei’j’thema after two weeks and a desquamation of the 
superficial layers of the skin within another eight daj'S. The latter will 
heal readily within two weeks. 

The gamma rays of radium have been measured by Glasser and Mautz 
in r units and they showed the erythema dose of gamma ra 3 ''S of radium 
to be 2000 r. Accordingly a 50 milligram element radium capsule in- 





SCHMITZ: TECHNIC OP RADIATION THERAPY 


15 


serted intracoi'porally into the cervical canal for 4800 mg. ei. hr. ■will 
give at a distance of 4 cm. 2500 r and at 5 cm. 1450 r. The intensities 
measured in i’ maj’' therefore he determined by the equal intensity curves. 
Should the determinations of r values of gamma rays by Glasser and 
Mautz be correct then our values for isodoses 5 and 21/2 muU have to be 
corrected. Instead of 25 per cent E. D. or 500 r at isodose 2.5 the value 
in r would be about 667 r as 2000 r measured with gamma rays produce 
a full erythema dose. 

The minimum wave length of radiations should always be Imown. 
Spectrometric analysis of the roentgen radiation gives the only absolute 
control of radiations. We use a Seeman spectrograph. Spectrographic 
measurements are seen in Figure 2. The minimum wave length of x-rays 
produced with 211 Kilovolt, 1 mm. copper and 1 mm. aluminum filter 
and 25 milliamperes is 0.06177 A. U. The effective wave length of the 
bundle of rays indicated by the shadow extends from 0.06177 to 0.26 
and the average wave length of the entire bundle is at 0.12354 Angstrom 
Units expressed as A. U. Hence the effective wave length is about twice 
the minimum wave length. 

If the peak voltage is known, which may be measured by a sphere gap, 
then the minimum wave length may be calculated by dividing the 
Planck constant 12.354, expressed p, ivith the peak voltage, designated 

V, i.e. or ^^=0-06177 A. U. (One A. U. = 10-^ cm. or 

0.00000001 cm.) Thus minimum wave lengths for all peak voltages can 
be calculated as seen in Table I. 


Table I 

The Determination of the Minimum 'Wave Length in A. D. by the Equation 


p 

-^ = X IN Which p is 12.354 and Y the Peak Voltage 


VOLTAGE 

JIINIMUM 

■WAVE LENGTH IN A. H. 

EFFECTIVE "WAVE LENGTH 
CALCULATED AS 2 N 

100,000 

0.12354 

0.24708 

200,000 

0.0G177 

0.12354 

300,000 

0.04178 

0.08956 

400,000 

0.03038 

0.06076 

500,000 

0.02471 

0.04942 

600,000 

0.02089 

0.04178 

700,000 

0.01763 

0.03526 

800,000 

0.01543 

0.03086 

900,000 

0.01372 

0.02744 

1,000,000 

0.01235 

0.02470 


OUTLINE OP TREATMENT 

The patient enters the hospital thirty-six hours before the scheduled time of treat- 
ment. A complete blood count including differential count, blood chemistry and 
Wassermaun test, virulency test of cervical and vaginal secretions, hydrogen ion de- 
termination of cervical and vaginal secretions, cystoscopy, and proctoscopy are done. 

Blood chemistry is important to determine retention of nitrogen. Eadiations 
should be given guardedly and controlled by subsequent nitrogen determinations if 





16 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGT 


retention is present at the first examination. Radiations cause an increase in the 
retention of the blood nitrogen. If this is added to a retention already existing a 
tox-emia might ensue proving lethal to the patient. 

A hemoglobin percentage of 50 or less, a red coll count of 2,500,000 or less, and a 
leucopenia contraindicate radiations as the existing anemia will rapidly increase 
from the large doses of radiations necessary for the treatment of carcinomas. In 
such instances an arrest of bleeding and discharge should be sought by an applica- 
tion of 50 mg. radium element intracer\-ically for twenty-four to thirty hours. 
Should the anemia improve due to arrest of hemorrhage and septicity then a complete 
treatment may bo carried out. Transfusions of whole blood may bo necessary, 

Tho viruleney test is .adapted to the technic of Phillip and Huge. A positive re- 
action contr.aindicates all local manipulations. The infection should be combated 
with antiseptic douches, and roentgen radi.ation may bo given in the meantime until 
a negative viruleney test is obtained, when radium insertions can be safely made. 

Tho hydrogen ion test is made from a purely investigative vieu'point. It has been 
stated that tho Pn turns towards the acid side in tho presence of c.areinoma and we 
desire to find out how early this phenomenon may appear. 

At this time the outline of the pclris is taken with the caliper and entered on 
tracing cloth. 

Cj’stoscopic and proctoscopic examinations arc made routinely. Invasion of the 
rectal or bladder wall is a contraindication to the uso of radium. However, roentgen 
r.ays may be given. 

If all these tests are neg.'itivc then contrjiindic.ations to tho insertion of radium 
do not c.xist. The patient is prepared surgically and is placed under gas .anesthesia 
tho next morning. V.aginal and binmnual examinations are again made and re- 
corded. Tho position, mobility, consistency, shape and depth of the uterus, tho di- 
rection of the uterine axis and tho extent of the carcinoma are determined and 
entered on the tracing linen. Afterwards the radium equal intensity curves axe 
entered (see Fig. 3). Tho linen tracing is then placed on the equal intensity curves 
of the roentgen rays, which are permanently cemented to a drawing board (see 
Pig. 4). Thereby it is possible to c.alciil.ato the tot.al radiation dose attained at any 
point within the pelvis. It should nowhere be liighcr than 4.5 E. D. throughout the 
radi.ation fields and this dose must bo scattered in fractions over fifteen to thirty 
days. 

After dilatation of the cervical canal a biopsy specimen is taken and the radium 
capsule containing SO mg. element and having .a wall thickness equal to 2 mm, brass 
placed intracervically. Firm packing pushes the bladder and the rectal mucous 
membranes away as far as possible. A retention catheter is placed in the bladder 
to keep it empty. The radium insertions are repeated tvrice at eight day intervals. 
On the intervening days roentgen ray treatments are given. The duration of treat- 
ment depends on the calculations made on the tracing (see Fig. 5). The patient is 
permitted to be up and .about during intervals between the radiation. 

The technic of radiation in carcinomas of the uterine body is as follows; The 
uterine camty forms a triangle, the apex is at the internal os, the base is formed by 
the fundal wall. The distance from one tubal uterine os to the opposite tubal uterine 
os measures from 2.5 to 3 cm. The loss of intensity at a distance of 3 cm. is one- 
ninth of the dose attained at the radium tube. Since a tandem applicator cannot be 
fixed in its location within the uterine wall and may lie tow.ords one or the other 
lateral walls a homogeneous dispersion of rays is problematic.al when using a tandem 
applicator. A “Y” shaped radium applicator has been constructed which permits 
a separation of the upper arms after it is inserted in the uterus. The set screw is 
marked and indicates the separation of the arms attained (see Figure C). The equal 
intensity curves ha’re been drami in and they show that the intensity attained at the 
periphery of the uterus is 4 E. D. if 50 mg. of radium element are inserted in each 


SCHiriTZ; TECHNIC OP RADIATION THERAPY 


17 


arm and tlie stem and applied for fourteen hours at eight day intervals for a total 
dose of 6300 mg. el. hours. Henee the distribution of the radium intensities with the 
T-applicator seems to he very homogeneous and will attack the entire carcinoma 
with a lethal dose if the carcinoma is limited within the boundaries of the uterus. 



\l\X\m\^\h\7\8\^\IO 


F/g. 3 . — Equal intensity curves of 50 mg’, el. radium filtered with 2 mm. brass measured 

in water. 



Pig. 4 . — Equal intensity curves of x-rays measured in water using the factors: 
211 K. V., 0.12354 A. U. effective wave length; 65 cm. focus skin distance; 1.0 mm. 
copper plus 1.0 mm, brass filter; 15 by 20 cm. size of field; 25 milliampere load. 


Invasion of the iliac and inguinal Ijunph nodes indicates roentgen irradiation. Pour 
fields are used, namely one over each inguinal region and one over each buttocks 
region. The center of the pelvis is excluded from these radiations so not to cause an 
overradiation in the uterus, bladder, and rectum. 

Badiation sickness is not frequently seen. Eadiation cystitis and proctitis occur 
almost invariably, usually at the time the entire treatment has been concluded. 
They are self-limited and terminate within two to three weeks. Lithium benzoate in 


18 AMERICAN JOURNAL OF OBSTETRICS AND GTNECOLOGT 

10 gm. doses well diluted and given every three to four hours relieves the bladder 
tenesmus. Radiation proetitis is best treated with suppositories of cocoa butter aud 
opium, and a bland diet. In very severe cases fl. extr. coto bark, bismuth subtannate 
and eventually deodorized tincture of opium in mistura crctac have given better re- 
sults than any other medication. The skin erythcin.a and epilation arc treated with 



Fig. 5. — Transverse section tlirougli female pelvis just above symphysis pubis. 
Equal intensity cairvcs Irom radium capsule placed intrauterine are drawn in circles, 
the radii being taken from Fig. 3. They are designated 50, 100, 200, 400, and GOO re- 
spectively whicli also designates the percentage of erythema do.ses obtained with a 
4S00 mg. el. hr. application. They are dr.awn in interrupted line.s. Tlie equal intensity 
curves of roentgen rays obtained through anterior and jmsterior fields are drawn in 
solid lines in one-half of the section. The percentages in relation to the surface intensity 
are given as DO, "0, 50, etc. 



Pig. 0. — Longitudinal section through pelvis with same legends as for Pig. 5. 

Dodd’s lotion applied on cotton mornings and evenings. Profuse vaginal discharge 
reacts weU to astringent douches. 

The diet is a very important means of counteracting the systemic reactions due 
to radiation. Codliver oil, viosterol, copper and iron, milk, me.ats, cereals, fats are 
relied on. Vegetables and fruits are restricted. 






SCHMITZ: TECHNIC OP RADIATION THERAPY 


19 


Withm six to tTrelve weeks the eonvaleseent period should have ended and the 
cervix should he healed. If it has not healed we deem it unwise to repeat irradiations 
and rather prefer to remove the uterus if it can be done. However, should a recur- 
rence occur after a primary healing then the ulceration is treated with interstitial 
radiation. Platinum needles filled with one, two or three radiuni cells each of 
1 mg. el, strength are inserted at a spacing of 1 cm. from each other. Por each esti- 
mated cubic centimeter of tissue 120 mg. hours of radium are required. It is best to 
place the radium needles into the periphery and not into the active growth. Other- 
Avise it is not advisable to repeat a complete course of radiation treatment. 



P'B- I.-— Schmitz' Y-shaped radium filter for treatment of carcinoma of the uterine 
body. It also makes an ideal applicator for the treatment of hemorrhagic metropathies 
and myomas, as the capsules are held in each uterine fundal angle and thus uninten- 
tional cauterization of the internal os is avoided. 

Latent complications are stenoses of the cervical canal with pyometra. The pa- 
tients complain of a mid-pelvic pain, relieved by a sudden discharge of a large 
amount of purulent fluid. Dilatation of the canal and insertion of a rubber T drain 
tvill relieve the complication. Lateral pain in the pelvis usually indicates compres- 
sion or invasion of ureters with retention hydronephrosis. Ureteral catheterization 
and pyelography should be used to corroborate the clinical diagnosis. Dilatation of 
the ureter may cause temporary relief. In some instances in which the carcinoma had 
healed, resort to transplantation of the ureters rvas made. Several patients have 
thus been permanently relieved. Pressure on pelvic nerves is indicated by intense 
pain and often paralysis of the extremity. Eepetition of the roentgen treatment may 
give the patient relief. Patients unable to rvalk on entrance to the hospital have re- 
acted so speedily to the scattered fraction method that they left the hospital walking. 

It is obvious that changes in the radiation technic were made with an improve- 



20 


AJIERICAK JOURNAL OF OBSTETRICS AND GYNECOLOGY 


Table II 

Factors Used in Roentgen Treatment for Each Period to Show Progress 
IN Development of Technic 


Periods 

1914-1919 

1920 - 1921 

1922 - 1923 

Since 1924 

Transformer 

Snook Cross Arm Tj'pe 

Cross Arm Tj-pc to Deliver 
300 Kv. 

Type of Tube 

Standard Coolidgo Tre.atment 
ivith Broad Focus 

200 Kv. 
Air-Cooled 
Coolidgc 

250 Kv. 
Water-Cooled 
Coolidge 

Pe.ak Kilo Voltage 

110 

140 

211 

211 

Filter: Copper 
plus Aluminum 

G mm. Al. 

0.5 mm. Cu. 
plus 1.0 mm. Al, 

1.0 mm. Cu, 
, plus 1.0 mm. Al, 

, 1.0 mm. Cu. 

. phis 

1.0 mm. *il. 

Focus Skin Dist. 

■15 cm. 

05 cm. 

G5 cm. 

so cm. 

Size of Fields 

25 sq. cm. 

225 sq. cm. 

225 to 400 sq. 
cm. 

225 to 400 sq. 
cm. 

Number of Fields 

8 to 20 

2 to 5 1 

2 to 5 j 

2 to 5 

Dose to Ea. Fid. 

150 mamp. min. 

11050 m.amp. 

: min. 

1000 mfinip. 
min. 

1250 m.amp. 
min. 

Interval 

8 to 20 d.ays 

One fid. daily 

One hr. daily 

G to 15 days 

One fid. daily 

2 to 5 d.ays 

5 X 250 mamp. 
min. Every 
third day to 
each field 

Depth Dose 
at 10 cm. . 

iVbout 20% 

About 35% ^ 

14% 

18% 

Units in “r” 


< 

iOO without 1 

Backscatter 

[200 without 
Backscatter 


ment in apparatus. Table II shows tho periods and the factors for each one of the 
periods. In the near future a 1,000,000 kilovolt tr.ansforiner and a cascade tube able 
to carry a load of 900 to 1000 kilovolts will be installed. The statistics presented in 
Table III demonstrate that tho live year good end-results improved with each im- 
provement in the roentgen technic as the r.idium dose has alwtiys remained the same. 
Ono may anticipate an improvement in good end-results with the use of such ultra 
short wave length roentgen rays, as the biologic reaction increases in direct propor- 
tion to the decrease in the wave length of the rays. 

SUMMARY 

1. The physical principles of the production of x-rays and radium 
should be Imown to obtain the best results in the treatment of malignant 
diseases by irradiations. 

2. The methods of application, the scattered fraction method of treat- 
ment, the factors which describe the quality of the rays, the definitions 
of the erythema dose and the international roentgen unit, termed r, have 
been discussed. 

3. The dose is the product of the radiation intensity and the time and 


SCHJIITZ; TECHNIC OP EADIATION THERAPY 


21 


Table III 



PERIOD 

: 1914-1919 


1920 AND 

1921 


Clinical Group 1 

Total 

2 

3 4 

Total 

1 

2 3 

4 

Total 

number admitted 5 

16 

76 35 

132 

9 

13 26 

29 

77 

Total 5 year 

good end-results 5 
Per cent 5 year 

7 

7 0 

19 

6 

6 2 

0 

14 

good end-results 100.0 

43.75 

9.21 0 

14.39 

66.67 

46.75 7.69 

0 

18.38 

PERIOD : 

1922 AND 1923 


1924 - 1927 


Clinical Group 1 

Total 

2 

3 4 

Total 

1 

2 3 

4 

Total 

number admitted 9 

19 

59 36 

123 

12 

14 61 

69 

156 

Total 5 year 
good end-results 7 
Per cent 5 year 

7 

11 0 

25 

10 

6 16 

3 

35 

good end-results 77.78 

36.84 18.65 0 

20.32 

83 

42.85 26.23 

4.35 

22.43 

GRAND TOTAL 1914-1927 

Clinical Group 


1, 

2 

3 

4 

Total 

Total number admitted 

35 

62 

222 

169 

488 


Total 5 year 
good end-results 
Per cent 5 year 


28 

26 

36 

3 

93 


good end-results 


80.0 

41.94 

16.36 1.72 

19.14 


has been given in E. D. and r. Tbe effective wave length measui’ed with 
the spectrograph gives the only absolute control of the quality of rays. 

4. The use of equal intensity curves of radium and x-rays on the trans- 
verse diagram of the patient’s pelvis has been demonstrated. Tliereby it 
is possible to apply an intense radiation dose of 4 to 5 E. D. throughout 
the pelvis, this dose being considered lethal to the majority of uterine 
carcinomas. Irreparable injuries to the pelvic organs by the rays can 
only be avoided by the use of the equal intensity curves and the diagram. 

5. The preparation of the patient, the contraindications to radiation 
therapy , and the treatment of local and systemic complications have been 
considered. 

25 East Washington Street. 


REFERENCES 

T Prime, F.: J. A. M. A. 74: 308, 1920. (2) Wood F G • 

52^1^25^' a) J- ^entgenol.' w': 

230. (17) CW, 0., a,a Mc.„, F. J. SlgeS. iS 







AN ANALYSIS OF THE MENSTRUAL CHANGES IN 
TUBERCULOUS WOMEN^^ 

Edwin M. Jameson, B.S., M.D., Saranac Lake, N. Y. 

OTLDENTS of tuberculosis are constantly being reminded of the pro- 
found alterations in the physiology of unrelated organs and systems 
which are bi’ought about by the presence of an active tuberculous process 
in the lungs, intestines, or elscwhei'c. Pulmonary tuberculosis especially 
can no longer be regarded as a disease of the lungs alone but rather as a 
systemic condition whose presence is reflected in every tissue of the body. 

The pathologic physiology' of the gastrointestinal tract, the blood, the 
nervous and circulatory systems in patients suffering from tuberculosis 
has been well worked out and numerous studies have been made on the 
blood pressure variations and basal metabolic rates, but in no system, 
pei'haps, are the changes so manifest as those found in the physiology of 
the female genital tract. Other investigations of these changes have 
been made, notably by Norris and Slacht, but none, so far as we have 
been able to determine, from the same angle as that which follows. 

This report is based upon an analysis of 200 detailed menstnial his- 
toi'ies obtained eonsceutivcly from women at the sanatoria in and 
around Saranac Lake. All of these patients have active pulmonary 
tuberculosis; 22 have intestinal, 3 laryngeal, and one cervical gland 
lesions in addition. The ages vary from sixteen to forty-eight, with the 
largest group falling in the third decade of life. With the exception of 
minor treatment for Icucorrhea and a few instances of curettage, none 
of the patients in this series had had operations on the genitalia. 

While it is appreciated that this series is small and that there are far 
too few' cases in the various groups W'hen the subdivisions have been 
made to w'arrant any definite conclusions, this report w'oukl seem to be 
of interest for the purpose of demonstrating trends rather than that of 
actual figures or percentages. 

An analysis of the age groups show's 13 in the sixteen to twenty group ; 
125 between tw'enty and thirty; 47 betAveen thirty and forty, and 15 
over foi’ty j'ears of age. The group over forty is small because of the 
confusion w’hich may arise Avith sj'mptoms of the menopause. On the 
basis of extent of disease according to the National Tuberculosis Associ- 
ation classification, there Avere 34 minimal, 114 moderately adA'anced, 
and 52 far advanced cases. 

The age of puberty w'as thirteen and four-tenths years for the minimal 
cases; tAvelA'e and eight-tenths years for the moderately advanced, and 
thirteen and nine-tenths yeai'S foi’ the far adA'anced patients. This is 

‘Read, by invitation, at a meeting of the New Yorlc Obstetrical Society, March 8, 
1D32. 


22 



JAMESON : MENSTRUAL. CILANGES 


23 


unexplained as the average age for the various groups is practically 
identical (tAventy-seven and five-tenths years). 

In answer to the question, “Have you noticed any change in your 
menses since beginning the cure?” 55.8 per cent of the minimals, 58 per 
cent of the moderately advanced, and 67.3 per cent of the far advanced 
cases ansAvered in the affii’mative. All of these changes Avere not for the 
AA'orse as an appreciable number reported a return to a tAventy-eight-day 
interval or improved floAv, since entering the sanatorium. When calcu- 
lated on the basis of age groups, 55 per cent of the girls under thirty 
shoAved changes since the onset of tuberculosis and 68 per cent of the 
patients over thirty. This latter increase is not due to the approaching 
menopause as the percentage is the same for the fourth and fifth decade 
groups separately. 

Previous to the onset of tuberculosis 20 per cent of the entire series 
gave a history of irregularity; since the diagnosis of tuberculosis has 
been made 26 per cent have been irregular. The extent of the disease 
seems to have but little influence on the incidence of irregularity as 
shoAvn in Table I. 

Sixteen and one-half per cent of the series have had longer inter- 


Table I. Irregulaeitt 



BEFORE 

TUBERCULOSIS 

SINCE 

TUBERCULOSIS 

Minimal 

20.6% 

29.4% 

Moderately Advanced 

17,.5% 

23.6% 

Far Advanced 

25 % 

29 % 

Total 

20 % 

26 % 


menstrual periods since the onset of tuberculosis AA'hile 18 per cent re- 
port shorter intervals and 66.9 per cent no change. As shoAAm in 
Table II, the minimal cases shoAV the greatest incidence of change and 
the incidence of longer or shorter intervals is very similar for all groups. 

The average number of days of floAv for all groups is four and nine- 
tenths before the onset of tuberculosis; four and six-tenths days since. 
The minimal cases decreased on the average from five to four and six- 
tenths days; the moderately advanced from five and one-tenth to five; 
and the far advanced from four and eight-tenths to four and three-tenths 
days. We are unable to explain the discrepancy in the moderately ad- 
A^aneed group. 

A history of flow lasting more than six days, exclusive of puberty or 
miscarriages, Avas given by 20.5 per cent of the minimal, 18.4 per cent 
of the moderately advanced, and 11.5 per cent of the far advanced cases. 
This makes an average figure of 16.8 per cent for the entire series and 
suggests that lijqAermenorrhea becomes less common as the disease 
progresses. 

Taking a history of one or more periods skipped (exclusive of the 





24 AMERICAN JOURNAL OF OBSTETRICS .VXD GYNECOLOGY 

first years after puberty, pregnancy, and operated eases) as a criterion, 
13 per cent of the minimal cases, 27 per cent of the moderately advanced, 
and 26 per cent of the far advanced eases had had periods of amenor- 
rhea. These figures are strikingly high when compared with those of 
Norris. It is our impression that the onset of the disease or an increase 


TaRLE TI. LESGTII of ISTEmiEXSTnUAh Pekiod 



LOKOER 

SHORTER 

NO CHANGE 

Minimal 

23.5% 

20.0% 

60 % 

Moderately Advanced 

15 % 

17 % 

OS % 

Far Advanced 

15.0% 

17.0% 

C6.S% 

Total 

10.5% 

IS %. 

00.9% 


in the lesion is llie commonest time for the appearance of amenorx-hea 
and that, while tlic incidence in the moderately advanced and far ad- 



Pip. I. 


vaneed groups is the same, wlien once established it tends to last longer 
in the fai’ advanced cases. That age is also a factor is evident when we 
see that the incidence in patients below thirty is 18.8 per cent while for 
those over thirty it is 32 per cent in each decade. 

Of similar interest was the histoiy of intei'menstrual bleeding, ex- 
clusive of miscarriages, since the onset of tuberculosis. In the minimal 
group, there were 4 cases ; in the moderately advanced 7, and in the far 
advanced group 3 patients with a histoiy of metrorrhagia since coming 
to the sanatorium. The incidence for the entire series is ( per cent with 
a frequency twice as great in the minimal eases as in the other two 
groups. 

We have had occasion to curette a number of these cases of metior- 
rhagia in tuberculous women with the hope of making a diagnosis of the 
cause. The findings have been very confusing as the mici’oscopic picture 
varies from that of an apparently normal resting endometiium thiough 
that of the different cyclic changes. A few cases of undoubted endome- 


JAMESON: MENSTRUAL CHANGES 


25 


trial hyperplasia have been encountered but in a large proportion^ of 
cases the pathologist was unable to solve the question of why bleeding 
occurred (Figs. 1 and 2). 

The differences in the amount of flow for each group since the onset 
of tuberculosis is shoum in Table III. It will be seen that there is a 
greater tendency to no change or a decrease than towards more flow in 

all the groups. _ , m 

DysHiGnorrliGO. 'wotilcL sggih. to 1)6 3. coTnmoii complsiTvtj althoTigli ToDlGr 

and Schaffer find that 70 to 75 per cent of otherwise normal women 
suffer moi’e or less at the time of flow. This series shows a slight in- 
crease in the total number of cases of dysmenoi’rhea in each group since 
the onset of tuberculosis, but a significant rise in the number of severe 
cases. Table IV shows the type of dysmenorrhea. The percentages are 
figured on the total number of eases of dysmenorrhea in each class of 



tuberculous lesion rather than upon the entire group. Calculated on the 
basis of the entire series, 68 per cent of the tuberculous women had 
dysmenorrhea divided as follows: 18.3 per cent congestive type, 53 per 
cent obstructive, 28.6 per cent mixed, and one case of postflow pain in a 


Table III. Amount of Tlow 



UNCHANGED 

MORE 

LESS 

Minimal 

67.7% 

14.7% 

17.6% 

Moderately Advanced 

81.7% 

6.1% 

12.2% 

Far Advanced 

69 % 

5.7% 

25 % 

Table IV. Type of Uysmenoerhea 

EXTENT OP DISEASE 

FRESIENSTRUAIi 

HENSTRTJAL 

MIXED 

Minimal 

29.0% 

50 % 

28 %, 

Moderately Advanced 

16.0% 

55.5% 

28.4% 

Far Advanced 

16.0% 

48.4% 

35.5% 

Total 

IS.3% 

53.0% 

28.6% 



26 


AJIEUICAN .TOUHNAE OF OBSTETRICS AEO GYNECOI.OGY 


single girl whose menses lasted three to four days and whose pain ap- 
peared on the fifth day. As only nine girls in the entii'c series weighed 
less than one luindrod pounds (five of whom had no dysmenorrhea and 
the remainder no more or no less than they had before the onset of 
tuberculosis), the theory of malnutrition as a cause of menstrual pain in 
tubei’cnlous women does not seem tenable. 

Additional data on the que.stion of dj’smenorrhea is given in Table V 
whore the pain is cla.ssified as mild, moderate, or severe. This is an 
arbitrary grouping and depends upon the patient's own reaction to her 
pain. The table also shows that about 10 per cent of the girls have less 
pain than tbcj* bad before and a somewhat larger number moi'e. 

Symptoms other than pain noted by these women ai’C shown in 
Table VI. Wliile no figures are at hand to support the contention, we 
believe that an equal number of so-called normal women would show 
about the same results with the exception of the lai'gc number who com- 
plained of prostration and pi'cmcnstrual, menstrual and postmenstrual 
elevations of temperature. In this study premenstrual and menstrual 
fever was taken to be 99° F. or over, while in a previous analysis, some- 
what more accurate criteria were followed and a lower incidence dis- 
covered. It is our impression that the menstrual elevations of tempera- 

TaBLE V. DT.SMEKOnnUF.A 




MODFJtATELY 

FAR 


MINIMAL 

ADVANCED 

ADVANCED 

None 

32.3%. 

32.4%, 

44.2%, 

Mild 

8.8%. 

24.5%, 

17.3% 

Moderate 

32.3% 

24.5% 

17.3%, 

Severe 

20.4%. 

18.4%, 

21.1% 

Less Since Onset 

11.7%. 

10.5%. 

10.0% 

More Since Onset 

17.0% 

12.2%, 

12.0% 

Table VI. 

Number of Cases Siiowino Sy.mptoms Other Than 

Pain 



moderately far 


SYMPTOM 

MINIMAL 

ADVANCED ADVANCED 

total 


DJstention 

Diarrhea 

Sore Breasts 

Nausea 

Headache 

Fatigue 

Vomiting 

Weakness 

Irritable 

Syncope 

Epistaxis 

Nervousness 

Vertigo 

Hysterical 

Prostration 

Premenstrual* Fever 

Menstrual Fever 

Postmenstrual Fever 


0 

0 

0 

1 

6 

3 

0 

0 

2 

0 

0 

2 

1 

0 

5 

58.8% 

14.7% 

5.9% 


0 

o 

4 

3 

19 

G 

3 


0 

0 

2 

0 

0 

29 

55.2% 

7.8% 

4.8% 


1 

0 

0 

2 

4 

1 

1 

0 

1 

1 

1 

3 

0 

1 

17 

59.6% 

7.6% 

3.8% 


1 

0 

4 

6 

29 

10 

4 
2 

5 

1 
1 
7 
1 
1 

51 

57.0% 

9.0% 

4.5% 


Premenstrual, menstrual, and postmenstrual fever is 93 P. or over. 



JAMESON: MENSTRUAL CHANGES 


27 


ture occur in patients Avho are not doing w'ell. The postmenstrual fever 
shown by the minimal cases Avas a continuation of the premenstrual and 
menstrual elevations; the same condition holds in the moderately ad- 
vanced and in addition half the eases were progressing. In the far 
adAmnced group both eases had intestinal tuberculosis and one, in addi- 
tion, who had a tuberculous larynx had chills and a temperature of 102 
to 104° F. on the first day after the menstrual period. 

The question of leueorrhea was studied in single women only and an 
incidence of 41 per cent for the entire group noted. It was contrary to 
our expectations to find the highest incidence among the minimal eases 
and the loAvest among the far advanced. The details are shown in 
Table VII. 

It is interesting to note that there is less leueori’hea among the tuber- 
culous women who are popularlj’’ supposed to he “run down” than oc- 
curred before they became ill. An intermittent leueorrhea is the more 
frequent type in all the groups, but there are proportionately more eases 
of a constant discharge in the minimal eases than in those that are ad- 
vanced. Similarly all the positive cases in the far advanced group had 
a scant discharge only, while 18 per cent of the minimals described it 
as profuse. 

We wore unable to show any definite relation between pregnancy and 
onset of tuberculosis in this series. Sixty married women have been in- 
cluded, of whom 34 have been pregnant. Twenty-seven went to term one 
or more times. Two patients dated the onset of their tuberculosis to 


Table VII. Leucorrhea (Single Women Only) 


TYPE 

llINIMAti 

MODERATELY 

ADVANCED 

FAR 

ADVANCED 

BEFORE SINCE 

TUBERCULOSIS TUBERCULOSIS 

Incidence 

44.0% 

38.2% 

41.0% 

46.0% 

41.0% 

Intermittent 

72.7% 

80.0% 

85.0% 

88.0% 

79.2% 

At Menses Only 

18.0% 

62.5% • 

33.0% 

38.6% 

37.8% 

Constant 

27.2% 

20.0% 

15.0% 

12.0% 

20.7%, 

Slight 

81.0% 

90.0% 

100.0% 

96.0% • 

90.0% 

Profuse 

18.0% 

10.0%, 

0 

4.0% 

10.0% 


abortions, and one moderately advanced case had a therapeutic abortion 
done after the diagnosis was made. One far advanced case, who has had 
tubereulosis for fifteen years, has had two babies, the last three years ago, 
and one miscarriage seven years ago. One moderately advanced patient, 
para ii, dated the onset of her tuberculosis to the time of her last con- 
finement but the evidence is not conclusive and another moderately ad- 
vanced case had a confinement six months before her tuberculosis was 
diagnosed. The remainder showed no relation whatsoever. 

Intestinal tubereulosis was present in 22 patients, but this complica- 
tion seems to have no influence on the incidence of changes in their 
menses since beginning the antituberculous regime as compared with the 
entire group. 




28 ASIEKICAN JOURNAL OF OBS'fETRICS ANO GYNECOI.OGY 

Of the so girls wlio gave a history of licmoptysis, an incidence of 40 
per cent for the series, 26 per cent reported tlie oecnrrenee of pulmonary 
hemorrhages only at the time the menses vere present; 53.7 per cent 
between periods ; 10 per cent showed no relation, and 10 per cent could 
not recall whether or not they wci-e menstrnating at the time. Thus, 
while hemoptysis did occur in 26 per cent of the cases at the time of 
catamenia, a cause and eifect relation is not clear except in the occasional 
case. One minimal case, a section of whose endometrium is shown in 
Pig. 1, “streaked” dailj' over a period of three and a half months, while 
we were endeavoring to stop her metrorrhagia with small doses of x-ray. 
Radium was finally used and when the uterine bleeding was stopped the 
pulmonaiy hemorrhages also ceased and have not recurred. 

The number of patients in this scries who were taking pnexunothorax 
is too small to xvarrant a detailed analysis but the findings have been of 
sufficient interest to stimulate the fiu’thcr study which is now in progress. 
Suffice it that in a large pei'eentage of cases the effects of collapse therapy 
appear to have a deleterious influence on the menstruation and only a 
few show the improvement noted by Caussimon. 

CONCLUSIONS 

No attempt can be made to draw up a list of definite conclusions from 
such a scries as is presented in this report, but the necessity of revising 
many of our former ideas of the influence of tuberculosis on the menses 
is apparent. Particularly is this tine of the questions of amenorrhea and 
the influence of collapse therapy on the menses. Whether or not men- 
struation, with the coincident lowering of capillaiy permeability, pre- 
disposes to hemoptysis is a fruitful field for fui-ther study and holds 
many possibilities. Ceidainly it is true however that tuberculosis exerts 
a profound effect through some as yet undetermined mechanism upon the 
menstrual cjmle and that we are only beginning to appreciate its true 
extent. 

The author wishes to express his thanks to Drs. Helen Hearts and John Bootli, with- 
out whoso assistance this report would not have been possible. 

REFERENCES 

(1) Norris, C. C.; Gynecological and Obstetrical Tuberculosis, New York, Apple- 
ton & Co. (2) Maclit, i), I.; Quoted by Norris ibid. (3) Toiler : Quoted by Norris 
ibid. (4) Schaffer: Quoted by Norris ibid. (5) Jameson, E. M., et al.: J. A. M. A. 
95; 13, 1930. (6) Caussimon, J.: Pussc Med. 37: 1557, 1929. 

6 Church Street. 

DISCUSSION ' 

DE. M. D. MAYER.— It seems to me that in the fairly advanced cases, ^ espe- 
cially in the third decade of life, it would be rational to advise routine radiation 
of the ovaries in order to give at least a one- or two-year complete amenorrhea. 

It is almost impossible in the first half at least of the third decade and at least 
unlikely in the second half of the third decade, to produce a permanent amenor- 
rhea with the pieeeable doses of x-ray. In a fairly large scries of therapeutic 



JAMESON": MENSTR'DAL CHANGES 


29 


abortions for tuberculosis, produced by means of x-ray, it has been found that 
the large majority of cases do very -well clinically as far as their tuberculosis 
is concerned after the incidental long-term amenorrhea "which occurs after the 
abortion has taken place. 

DB. HABVEY B. MATTHEWS. — believe it can be safely said that our con- 
ception of menstruation, pregnancy, and labor in relation to tuberculosis, will 
have to be more or less revamped. 

It may be in order to suggest that these menstrual disturbances could be 
brought about by at least three different pathologic conditions, First, the tuber- 
culosis itself; the constitutional change brought about by the tuberculosis in any 
of its forms, but more particularly the pulmonary type, may have something to 
do with these changes, because these girls do improve during an amenorrhea; sec- 
ond, the endocrine disturbances that we know go with tuberculosis, particularly 
pulmonary tuberculosis, may have, and undoubtedly do have considerable influ- 
ence on these changes; and third, changes in the blood chemistry may have 
something to do with these, since we know that the calcium content of the blood 
in tuberculosis is lowered, as it is during the menstrual and postmenstrual periods. 
So if the calcium coefficient is lowered in general tuberculosis, a constitutional 
■disease, then it is lowered further during the time of the menstrual flux. It 
would naturally, therefore, be supposed that there would be an exacerbation of 
the tuberculous process during the menstrual period. That is shown by the rise 
in temperature in 42 per cent. I believed this percentage was much higher. 

Formerly at Saranac Lake there was a good deal of opposition to the idea 
of an irradiation amenorrhea. There were quite a few patients who were suffer- 
ing from hemorrhages of various kinds and who also had severe dysmenorrhea. 
I suggested producing amenorrhea with radium, but the idea was not received 
favorably. However, several patients were irradiated and in every instance 
there was improvement in the tuberculosis. I would recommend a temporary 
amenorrhea in suitable cases. The "dosage'' of radium can now be fairly defi- 
nitely controlled, and I can see no harm in its use and I have seen much benefit 
accrue to the tuberculosis. "We have accumulated enough data to be fairly cer- 
tain that preconception irradiation is a perfectly safe procedure as regards future 
pregnancy. 

HE'. JAMESON (closing). — ^We got the idea of inducing amenorrhea in pul- 
monary tuberculosis from Herman authorities, but the local ultra-conservative 
group would not let us do it. I have had about six cases and all of them were 
improved. I talked to some of the girls, particularly at Stony "Wold, and they 
said they would be glad to have their menstruation cut out because they all felt 
very much worse at the time of their periods; and I believe I am correct in in- 
sisting that the lung findings arc always more marked at the time of menstrua- 
tion than at any other time. 

As regards calcium metabolism, the work done at Stony "Wold on the nondiffusible- 
diffusible ratio in the blood and spinal fluid, was found of no value in determining 
activity or prognosis. 

I am firmly convinced that these girls, who have a fever during the menstrual pe- 
riod, should have an amenorrhea established; it does not matter whether it is perma- 
nent or not in that case. Some men think the temperature during menstruation in- 
dicates a blood streanr infection with tubercle bacUfi, and the Germans and French 
claim that they have obtained tubercle bacilli from the blood stream. Several at- 
tempts have been made at Trudeau, but were unsuccessful in finding the tubercle 
bacillus in the blood stream. 



EPITHELIAL REGENERATION IN THE UTERINE GLANDS AND 
ON THE SURFACE OP THE UTERUS'" 

GEonGK N. Papanicolaou, M.D., Pxi.D., New Yoek 

(From ihc Dciiarlmcnt of Anatomii, Cornell University Medical College) 

/^NE of the chai'actoristics of the ’uterine cpitheliiuii is its periodic 
destruction and regeneration. The periodic loss of the epithelium 
oeeui’s during menstruation in the human being and in the primates 
and during estrus in the lower mammals. This reaction shows great 
variations in the various typos of mammals and in different individuals. 
In women, aeeox'ding to some investigators, only a small part of the 
epithelium and of the underlying .stroma is cast off. According to 
others, the -whoJe epithelium and a large part of the tunica propria, at 
least the whole of the compacta and most of the spongiosa, are elimi- 
nated. The last view can hardly be considered aiiplicablc to the average 
normal type. 

The regeneration of the uterine epithelium occurs -witli surprising 
rapidity. In guinea pigs, a complete replacement of the epithelium is 
found Avithin a few hours after its desciuamation. In Avomen, the I’e- 
generative processes begin as early as the third day of menstruation^ 
and dcA'clop veiy rapidly. Another siu'prising fact is the almost com- 
plete absence of mitotic figures during this early regeneratiAm stage. 
The actual proliferatiA'C phase, during AA-hieh a large number of mitoses 
can be seen, occurs later, AA’hen the ncAV epithelium is almost completely 
formed. These tAvo facts, i, e., the rapidity of the noAv epithelization 
and the lack of mitotic figures, cannot be accH explained bj’’ the generally 
accepted theory, that the uterine epithelium regenerates from the epi- 
thelium of the deep glands Avhich has escaped destruction, or from rem- 
nants of the old epithelium. 

In 1890, DuA'al,- and later Johnstone,^ and Heape,'* expressed the AdeAV 
that at least a part of the uterine epithelium regenerates in a different 
AAmy, by the actual differentiation of the superficial cells of the tunica 
propria. Duval pointed out that, since the uterine epithelium, as aa'cH 
as the tunica propria, Avere both of mesodermic origin, it Avas not incon- 
ceivable that such epithelium could be formed by a transformation of 
mesodermic cells. 

More than ten years ago, in studjdng the uteri of guinea pigs, killed 
at different times after copulation, I noticed that, in several specimens, 
the neAV uterine epithelium looked as if it Avere sudden^'' arising through 
a differentiation of the most superficial cell layers of the tunica propria. 
Being out of accord AA'ith such an interpretation on theoretical grounds 

♦Read, by invitation, at a meeting of the New Tork Obstetrical Society, Jlarch S, 
1932. 


30 



PAPANICOLAOU; EPITHEliIAL KEGENERATION 


31 


and realizing that the evidence offered by this material was insufficient, 
I did not continue the observations. Recently, however, in studying the 
epithelium o£ uterine glands, I have been ‘ffiipressed by, the fact that the 
epithelium in these glands is desquamated to the very tip of the gland 
and then a process of regeneration of an entirely neAv glandular epi- 
thelium quickly ensues. The changes within the glands did not appear 



Pig. 1. 



Pig. 2. 


to be synchronous with the changes on the surface of the uterus, and this 
may have been the reason why they escaped the attention of previous 
investigators. 

The desquamative and regenerative proeesses in the glands are much 
simpler and they clearly indicate that the new epithelium is formed by 
the actual differentiation of the superficial cells of the tunica propria. 



32 


AMERICAN JOURNALi OF OBSTETRICS AND GTKECOLOGY 


One may recognize a scries of stages succeeding one another in a typical 
fashion. First, there is a stage of desquamation, during -which the epi- 
thelium disintegrates and falls into the lumen of the gland, which is 
soon filled with a large number of desquamated cells and leucoejdes 
(T’ig. 1). 

The next stage is characterized by the gradual differentiation of the 
superficial cells of the tunica propria. These cells arc small and have 
a round or slightly elongated, oval, or elliptic nucleus and a very small 
amount of cytoplasm (Pig. 1). They resemble undifferentiated embry- 
onic cells and are very abundant Avithin the tunica propria. Their 
nature has been the subject of a great deal of controversy. We adhere 
to Minot’s view considering them to be embryonic in character. These 
cells become rounded and graduallj' form a continuous lining on the 
surface of the naked gland (Fig. 2). 



Fig-. 3. 


A period of growth noAV follows during Avhich these cells, as Avell as 
their nuclei, become lai’ger and display a pi-ogressive differentiation from 
a round to a euboidal form (Pig. 3). In continuation of this, an exten- 
sive proliferation is initiated during which a large number of mitoses 
can be seen (Pig. 4). The mitoses appear, en masse, Avhen the neiv 
epithelium is totally differentiated and are more numerous near the sur- 
face. They evidently represent an active proliferation of the nearly 
formed epithelium. 

Similar changes and a corresponding succession of stages occur at the 
surface of tho uterus. In tjqiical cases the Avhole of the utei’ine epithe- 
lium is east off (Pig. 5). Below this, a basement membrane is often 
seen connected with cells resembling fibroblasts. Such a membrane ap- 
pears also in the glands and is usually cast off with the epithelium. The 
superficial undifferentiated cells of the uterine wall are now grouped 



PAPANICOLAOU: EPITHELIAL EEGENERATION 


33 


together in a heavy, compact zone which reminds one of the eompacta, as 
it has been described in the human being during premenstruum and 
menstruation (Fig. 5). Hitschmann and Adler'^ and others, who de- 
scribed this zone, considered it as a differentiation of a false decidua. 
In the light of the present investigation, it seems to represent a heavy ac- 
cumulation of undifferentiated cells near the surface of the uterus as a 
preparation for the formation of the new epithelial lining. 



Fig. 5 . 


Soon after this the growth plienomena are initiated. The most super- 
ficial cells become rounded, larger in size, and form a continuous epi- 
thelial layer (Figs. 6 and 7). This new epithelium is gradually separated 
from the underljdng undifferentiated tissue and takes on a cuboidal 
form. The proliferative phenomena appear after the new epithelium is 
alread 3 ’- formed (Fig. 8). The mitotic figures are numerous and usually 
located near the surface of the epithelium, as in the glands. It is thus 



d4 AMERICAN JOURNAL OP OBSTETRICS AND GTNECOLOGr 

evident that the restoration of the epithelium occurs before the ap- 
pearance of typical proliferative phenomena. 

The existence of cyclic cliangcs in the epithelium of the uterine glands 
is of particular interest, because it provides new material for the study 
of the uterine epithelial regeneration. The changes occurring on the 
surface of the uterus are very complex and atjTjical due to several dis- 
turbing factors. One of these is Die extreme abundance of glandular 



Fig:. 7. 


ducts ending very close one to another on the surface of the uterus. 
When the new epithelium is formed, it is almost impossible to decide 
whether the regeneration began on the surface of the uterus, within the 
glands or simultaneously in both. It is often possible to interpret the 
same figure in three different ways, without definite pi'oof of the cor- 
rectness of any. This disturbing factor does not exist in the deep glands. 
When the epithelium is desquamated from an entire gland, there is 
practically no trace of old epithelium left to account for the sudden 
reappearance of a new epithelial lining. 



PAPANICOLAOU : EPITHELIAL REGENERATION 


35 


Another confusing factor is the often extensive destruction of large 
pieces of tunica propria on the surface of the uterus along with its epi- 
thelium. This creates an irregular healing surface, greatly complicating 
the simplicity of the new epithelial differentiation. In the glands it is 
only the epithelium and the basement membrane that are cast off, the 
tunica propria remaining almost intact. 

Groups of glands undergoing epithelial replacement are easily recog- 
nized by the large number of leucocytes and cellular detriment, filling 
their lumen. Confusion with glands undergoing cystic degeneration is 
practically impossible, because of the characteristic structure of their 
epithelium. 

These studies favor the view that the tunica propria of the uterus con- 
tains a large number of undifferentiated cells of mesodermic origin, 



Pig. 8. 


which, under favorable conditions, may form epithelial tissue. This oc- 
curs on the surface of the uterus, soon after the old epithelium is cast off 
and also within the deep uterine glands. The new epithelium is com- 
pletely formed within a very short time. Growth and proliferative 
phenomena appear later. The I'eplacement of the epithelium within the 
uterine glands is a much simpler process than the replacement of the 
epithelium on the surface of the uterus and offers excellent material for 
an accurate study of this problem. 

Note: This work has keen aided by the Committee for Eesearch on Sex Problems 
of the National Eesearch Council. 


REFERENCES 

(1) Nova!:, E., and Te Linde, E. TV.: J. A. M. A. 83: 900, 192A (2) Euval, M.: 
Compt. rend, de la Soc. de Biol. 2: 697, 1890. (3) Johnstone, A. TV.: Am. J. Obst. 

S'eape, TV.: Phil. Trans. Eoyal Soc. London, B., 188: 135-166, 
1 1908 L.: Monatschr. f. Geburtsh. u. Gynak. 27: 

DISCUSSION 


DE. J. A. COESCADEN.— Is it fair to say that the connective tissue elements 
of the endometrium can become epithelial because they are of the same mesoblastic 
origin? 



36 


A5IERICAN JOURNAL OP OHSTETRICS AND GYNECOI.OGY 


DE. G. N. PAPANICOLAOU. — The uterine epithelium is evidently formed by 
undifTerentiated, embryonic cells present tvithin the tunica propria and not by dif- 
ferentiated connective tissue elements. The fact that the epithelium as well as the 
tunica propria of the uterus .are both of mesodermic origin permits us to approve 
of such .an interpretation from .an cmbryologic point of view. 

UE. W. H. OAKY. — I would like to kno%v what relationship this might bear prac- 
tic.ally and clinically to the traumatism of too deep eurettement; whether destruc- 
tion brought about by curetting could interfere Avith the regeneration of the uterine 
epithelium. 

DE. G. N. PAPANICOLAOU. — suppose that the regeneration of the uterine 
epithelium after curettage occurs in the same Av.ay as normally, i. e., by a differen- 
tiation of embryonic tunica propria cells. We do not believe that destruction 
brought about by a mild curetting would interfere Avith the regeneration of the 
uterine epithelium, since numerous regenerative cells are scattered through the 
whole of the uterine mucosa. Of course a very deep eurettement might cause a cer- 
tain d.amage by destroying too much of the regenerative reser\-o cell material. 

DE. W. H. CAEY. — I am referring to curettage for hemorrhage in cases of in- 
complete abortion, ivhellier damage could bo done Avhore it is carried doAvn to the 
muscle, if the destruction could bo such .as to interfere Avith regeneration of the 
uterine epithelium. 

DE. G. N. PAPANICOLAOU. — Our discu.^sion on the regeneration of the uterine 
epithelium after curettage is purely theoretical, ns avc have not undertaken c-xperi- 
montal work along this line. Prom a theoretical standpoint we would be inclined 
to believe that a very severe eurettement carried doAvn to the muscularis would cause 
permanent injury to the uterine cpitheli.al Av.all and to its regenerative .ability. 

DE. MAYEE. — Am I right in assuming that Dr. Papanicolaou has found ex- 
actly the same pictures in human uteri .as in guinea pigs? 

DE. G. N. PAPANICOLAOU.— No. Wo Ji.ave not liad the opportunity to extend 
these observations to human uteri. The rcgoner.ativc changes within the uterine 
glands h.ave been found by us only recently in guinc.a pigs. Whether similar changes 
occur in the human Ave cannot definitely state. Wo find a suggestion of such changes 
in some of the photogr.aphs published by other investigators in the human being. 

The fact that the uterine glands during the very early stages of the epithelial 
replacement are filled Avith dead desquamated cells and phagocytes helps greatly in 
their identification even Avith a Ioav power. 

DE. G. L. MOENCH.— I would like to ask Dr. P.apanicolaou if he has seen any 
similar epithelial changes in the peritoneum. This membrane, lining the celom 
formed by the splitting of the njcsodcrm into tho splanchnoplcure and somato- 
pleure, is of pure mesodermal origin, yet in the AA'oman at times typical endome- 
trial glands seem to originate from it. Some of us consider the peritoneum to 
be the source of many adenomyositic processes. 

DE. G. N. PAPANICOLAOU.— I recall only ono case in which uterine glands 
were present within the myometrium in a guinea pig. The uterus Avas highly 
cystic and tho uterine wall greatly distended. Tho uterine mucosa was very 
thin. One could gather the impression that this invasion of mucosal elements 
Avithin the muscularis aa'Cs an abnormal condition caused by the action of degen- 
erative factors. Otherwise, I have not obserAmd uterine gland inclusions Avithin 
the myometrium in normal animals. It is difficult to offer anj' general interpre- 
tation for these peculiar morphologic discrepancies. 

DE. G. L. MOENCH.— What do you consider the stroma itself, outside of the 
mesoderm? 



HIRSCH AND JONES: EXPL.ANTS OF HUMAN ENDOMETRIUM 01 

DR. G. N. PAPANICOLAOU. — In tlic light of these investigations the tunica 
propria of the uterus seems to consist of two distinct groups of cells; some dif- 
ferentiated connective tissue elements and some undifferentiated embryonic cells. 
The presence of the last group gives a peculiar structure to the uterine mucosa 
and secures a rich supply of regenerative reserve material. Por an organ under- 
going repeated and extensive epithelial destructions, as the uterus does, this seems 
to represent a very well adapted morphologic structure. The same reserve mate- 
rial may be used for another useful purpose, i. e., the differentiation into decidual 
tissue. 


THE BEHAVIOR OP THE EPITHELIUM IN EXPLANTS OP 
HUIilAN ENDOMETRIUM'' 

Edwin P. Hirsgh, M.D., and Harold 0. Jones, M.D., Chicago, III. 

(From the Henry Baird Favill Laboratory and the Department of Gynecology, 

St. Ltilte’s Hospital) 

E xplants of human endometrium have been cultured for various 
purposes. In experiments concerned mainly with the growth in 
vitro of human malignant tumor tissues, thej’’ have been cultured inci- 
dentally ; in other experiments, they have been explanted with the pur- 
pose of testing Sampson’s theory of displaced endometrial tissue growth ; 
and finallj'’ in studies chiefly of an academic nature, endometrial tissues 
have been cultured to see what cellular structures, if any, grow. 

Cron and Gey‘ cultured endometrium recovered on the second day of menstrua- 
tion in a plasma medium containing heterologous embryonic extract. After several 
hours' incubation, they noted an activity of the cells and, for several days, a growth 
of leucocytes far into the medium. Tlie fixed tissue cells began to emigrate on the 
second day, when radial outgrowths of spindle cells and sheets of epithelium appeared 
at the periphery of the tissue fragments. The explants were transferred every four 
or five days for a month. Although these explants had vital properties, they were 
discarded because the tissue masses did not increase in size. Cron and Gey con- 
cluded that they had demonstrated viability of endometrial tissues removed by 
curette. Their cultures were not sectioned serially. IIeim“ cultured endometrium in 
a mixture of female human and chicken plasmas and chick embryo extracts. He re- 
ported the growth of a variety of cells, but his statements regarding the nature of the 
tissue cells growing about his explants are vague. Fragments of endometrium ob- 
tained by curette were cultured by Caffier’ on homologous and heterologous plasma 
containing embryonic tissue extracts or other fluids. None of these mediums con- 
sistently promoted growth : C.aflicr preserved the vitality of his explants only fourteen 
days. His ex-plants were stained in toto. He described membranes of cells around 
the explants, but the character of the cells participating in this growth was not 
mentioned. Traut,‘ with a fibrinogen solution and diluted embryonic extract contain- 
ing a trace of sodium linolate, maintained the growth of human endometrial explants 
about twenty days. His cultures were fixed, stained, and mounted in toto. The 
gron-th of new tissue, ho stated, was entirely of the stroma or connective tissue por- 
tions of the ex-plant; the epithelium, having a long latent period, was overgrown by 
the stroma cells. Conclusions based only on the microscopic examinations of living 
expltints or even preparations stained in toto are hazardous. None of the authors 


•This research was aided by a grant from the Watson K. Blair Fund. 



38 


AJIEniCAN JOURNAL OF OBSTETRICS AND GTNECOLOGr 


reported the study of explauted cudomctrium in serial sections, a method now con- 
sidered necessary. 

Aecorduigly to generally accepted histologic descriptions’ the lamina propria of 
the ondonietrium is a network of reticular fibers condensed into a basement mem- 
brane under the epithelium of the surface and glands. Tlsis fibrous reticulum is in- 
timately connected with many small polyhedr.al cells having small processes that 
anastomose throughout the tissues and adhere to the fibers of the reticulum. The 
small spaces between tiie cells contain wandering cells such as lymphocytes or granu- 



Fig. 1. — An explant four days old with focal regions of necrotic stroma. There Is 
only a slight hyperplasia of tlic glandular structures. x270. 



x270. 

lar leucocytes. In the deeper layers of the mucosa these colls may be numerous. An 
abundant supply of capillaries is distributed in networks under the surface epithe- 
lium and around the glands. The uterine glands are simple tubules lined by ciliated 
columnar epithelium. The variations during menstruation have been analyzed and 
described by Bartelmez." 

A study was undertaken to determine in serial sections the behavior of 
human endometrium explanted into a medium composed of human tissue 
fluids and to note especially any changes of the epithelium. 



HIRSCH AND JONES: EXPLANTS OP HUMAN ENDOMETRIUM 


39 


TJteri Temoved in tlie operating rooms were sent sterile to tlie laboratory and were 
kept for convenience at body temperature in an incubator not longer than one to 
three hours. Thin pieces of endometrium of 2 to 4 sq. mm. surface area then wore 
explanted into a medium composed equally of heparinized (1:10,000) plasma ob- 
tained from postpartum women and tissue extract made by crushing endometrium in 
Tyrode's solution. The cover glass method of tissue culture described by Maximow’ 
was used. The explants were transferred into fresh medium at intervals of one to 
three days. Certain cultures were useless because of contamination or failure to 
grow. The rapid liquefaction of the medium about the explants and the fragmenta- 
tion of the newly-grown tissue cells in the liquefied medium were further difficulties 
encountered. Seven seta of cultures were endometrial explants from women twenty 
to thirty years of age; sixteen were from women thirty to forty years of age; eight 
were from women forty to fifty years of age; and one was from a woman sixty -five 
3 -ears of age. 



Pig. 3, Photomicrograph of an explant fourteen days old illustrating the marked 
necrosis of the stroma tissues, the hyperplasia of the epithelium, and its orderly rela- 
tion witli the stroma. x270. 

Within twenty-four hours, as a rule, the medium about the explants was liquefied 
and a growth of tissue cells mainly of the polyblasts or l 3 Tnphoc 3 ’tes of the stroma 
extended about the margins. The surface epithelium thickened into two or three 
cell ]a 3 -ers and sometimes into small blunt sprouts. Some blunt sprouts broke away 
and formed small clusters of cells in the liquefied medium or stroma cells. The 
epithelium in the tubules thickened like that of the surface epithelium but without 
buds. Portions of the explants failed to grow; the loss b}- fragmentation in the 
liquefied medium and in the manipulations of transfer markedly diminished the 
mass of cells. Cultures surviving ten to fourteen da 3 ’s or longer were often reduced 
to dimensions of 1 or 2 mm. in diameter. Wheii, fortuitously, the cells grew on the 
surface of the medium with a minimum of liquefaction, thin sheets of polyblast cells 
equalling several square millimeters dimension, grew in twent 3 --four to forty-eight 
hours. The fibroblastic stroma ceUs grew out along the edge of only a few cultures 
as stellate cells with long fibrils. The epithelium after thickening into several layers, 
became relatively stationary and did not e.xtend in solid masses of cells into the 
medium. In fact, the relation of the epithelium to the stroma portions was main- 
tained in the explants in an orderly way just as in the tissues of the endometrium in 




40 


AMERICxViSr JOURNAL OF OBSTETRICS AND OTNECOLOGT 


vivo, with the exception of a sliglit liyperplasia. In a few cxplants, the growth of 
epitlieiium resembled that of an infiltrating carcinoma. This, however, was excep- 
tional. Tlic regeneration of epitholinin in tubules from the basal layers was observed 
clearly in certain cxplants where the lining epitlieiium had desquamated. The 
desquamated epithelium of such tubules occupied the lumen; a lining of regenerated 
epithelial cells had replaced those lost. Epithelial cells in mitosis were observed more 
frequently in the younger cultures than in the older. Small mats of cotton fibers in- 
troduced into tlic mediums with the e.vplants did not overcome the difficulties of tissue 
fragmentation. The epithelial cells in such cultures extended along the cotton fibers 
but thickened only into layers of two or three cells. Careful surface implantation 
of the cxplants made no appreciable difference in the growth of cells. Explauts 
grown under anaerobic conditions survived only a few days. The growth of tissues 
in these cultures was not different from those grown aerobically. Glycogen granules 
were not found in the epithelial cells of cxplants surviving seven to twelve days. 

cojryiENT 

The behavior of the epitlieiium in cx])lants of endometrium from uteri 
of women during the ehildbearing years, introduced into a medium of 
human plasma and endometrial tissue extraet, in some respects resembles 
but, in otliors, differs from that reported for the epithelium of embryos 
or young animals. Fischer’s® monograph described a gi-owth of epithe- 
lium in sheets on the surface of culture mediums following a short latent 
pei’iod. Groups of epithelial cells in these surface growths arranged 
themselves in rings which resembled cross sections of glands. Fischer, in 
old cultures, noted giant colls, retrogressive changes, and variations in 
the size and shape of the cells. He ascribed these to differences in the 
consistency of the medium or to the position of the explant in the 
medium. Wlien the growth of epithelium occuiTcd in membranes, ac- 
cording to Fischei', it was rapid and extensive, but when tubules formed, 
the rate of growth was much slower and the actual increase in mass was 
small. In some of iilaximow’s^ cultures of the mammary gland of .the 
rabbit, gi’c^ivtlis of epitlieiium resembling carcinoma occurred. Herzog’s® 
recent review summarized the studies on the behaxdor of epithelium in 
explants. In general, his conclusions were the same as Fischer 's. 

The gronlh of epithelium in the human endometrial explants of our 
cultures was not in sheets but was limited to a hyperplasia of the cells 
into several layers and small buds. The epithelium of explauts surnv- 
ing ten to fourteen days or longer covered the stroma portions of the 
explant in an “oi’ganoid” way, as Maximow proposed. Explants that 
sunnved a month had a little of the original fibrillar stroma tissues and 
were covered by a single lajmr of large cuboidal epithelial cells. 

These experiments demonstrate that the medium of human plasma and 
tissue extract prepared from human endometrium sustains life and pro- 
motes growth of the tissues in human endometi’ial explants at least a 
month, although after this time these activities are small. The tissues 
surxdving this length of explantation are mainly epithelium. Maximow 
thought that various stimuli may have contributed to the eareinoma-like 
growth of epithelium noted in his cultures of the rabbit mammary gland. 



BATES; BILATERAli KENAL AGENESIS OF FETUS 


41 


These, he stated, were (1) mechanical, the trauma of tissues; (2) chem- 
ical, the presence of some constituent of the tissue extract; and (3) the 
potentials of the epithelium in the host before explantation, such as its 
state of activity, and individual and racial peculiarities. The medium 
used in the cultures of endometrium probably contained constituents 
which occur regularly in endometrium liidng in the human body. It 
should produce no greater stimulus than that taking place with the usual 
cj'clic changes of the uterus. 

REFERENCES 

(1) Cron, Boland S., and Gey, George: Am. J. Obst. & Gvnec. 13: 645, 1927. 
(2) Heim, Konrad; Arch. f. Gynak. 134: 250, 1928. (3) Caffier, P.; Zentralbl. f. 

Gyniik. 52: 63, 1928. (4) Traut, Herbert F.: Surg. Gynec. Obst. 47: 334, 1928. 

(5) Maximow, A.: A Textbook of Histology, 1930, W. B. Saunders Co. (6) Bar- 
telmcs, G.: Am. J. Obst. & Gynec. 21: 623, 1931. (7) Maximow, A.: Virch. Arch, 
f. path. Anat. u. Phys. 256: 813, 1925. (8) Fischer, Albert: Tissue Culture, Copen- 

hagen, 1925, Levin and Miinksgaard. (9) Herzog, G.: Verhandl. d. Deutsche path. 
Gesellsch. 26; 9, 1931. 


BILATERAL RENAL A&ENESIS IN THE FETUS, ASSOCIATED 
WITH OLIGOHYDRAkINIOS 

Gaylord S. Bates, M.D., Detroit, Mich. 

(From the Department of Pathology, Harper Hospital) i 

C OMPLETE absence of both kidneys is an anomaly of great rarity 
and is apparently always associated with oligohydramnios, in itself 
a phenomenon rarely encountered. The report of two cases is thus of 
great interest as a matter of record and, in addition, invites attention to 
the question of the function of the kidneys in fetal life and of the 
source of amniotie fluid. 

Case 1. — Mrs. J. H., aged thirty, rvliite, para ii, entered Harper Hospital at 
2 P.M., September 22, 1930, a private patient of Dr. A. \V. Coxon, for an elective 
cesarean section. A section had been done three years previously for placenta previa, 
followed by a prolonged convalescence from postoperative pelvic infection. 

The last menstrual period was December 25, 1929. Estimated date of confinement 
October 1, 1930. Quickening at four months. In August there was bloody show 
for three days, with some uterine contractions. At the time of admission, the pa- 
tient was not in labor. Physical condition good. Urine negative. Fundus of uterus 
4 fingers below the xj-phoid. Fetal heart regular, rate 130. 

A classical cesarean section was done under .spinal anesthesia, using 150 mg. 
of novocaine. Amniotie fluid was entirely absent. Breech presentation found. The 
fetus was pink in color and seemed fully developed, but did not breathe except for 
occasional spasmodic gasps. In spite of various stimulants regular breathing could 
not bo established and the heart action ceased one hour after delivery. 

Postmortem examination demonstrated a well developed and well nourished fetus, 
length 45 cm., weight 1985 gm. There wore no deformities discernible by palpation 
or inspection. The internal organs were well developed and in their normal relation- 
ships except for the urinary system. In the position normally occupied by the right 
kidney lay a brownish kidney shaped organ 40 by 30 by 7 mm., weighing 4 gm. 
On the left side was a suuilar org.an 45 by 30 by 7 mm., weighing 5 gm. These 



42 


AMERICAN JOURNAL 01' OBSTETRICS AND GYNECOLOGY 


proved to be suprarenal glands. By following do%vn the remains of the urachus a 
rudimentary bladder with a rugous lining was found, whose internal surface measured 
9 by 0 inm. The urethral opening into the bladder was present but there were no 
ureteral openings. No ureters, or structures resembling them, could be demonstrated. 
The testicles were in the scrotum. 

The microscopic iindings were not remarkable. The placenta appeared normal 
in the gross and in the stained section. 

Case 2.— IMrs. R. B., aged twent}*-four, white, para iv, entered Harper Hospital 
far advanced in the second stage of labor at 9 r.ir., November 7, 1930, as a private 
patient of Dr. II. G. Alack. 



Fig. 1, — Dissection of abdominal cavity in fetus of Case 2. The suprarenals are 
readily seen as the large, thin ovoid bodies of Uie upper abdomen. Below the pght 
suprarenal is the right testis supplied by a brancli of the suprarenal artery. Just be- 
low the bifurcation of the aorta on the sacral promontory lies a small Irregular fibrous 
mass containing scattered hypoplastic glomerular bodies and fetal type tubules 
(Pig. 2), From its lower edge a fibrous cord extends to a pea sized bladder which 
may be identified as a grayish body lying in tlie pelvis. 

She had had 2 living children, followed by a stillbirth at eight months in June, 
1929, the cause of which was not determined. The last menstrual period was 
January 21, 1930. Estimated date of confinement November 2, 1930. Quickening 
at four months. This patient was seen at regular intervals throughout pregnancy 
by Dr. Alack, the last examination being one da}' before entry. Nothing abnormal 
was noted at any time. Petal movements were felt up to the onset of labor, which 
occurred a few hours before admission to the hospital. 




BATES: BILATERAL RENAL AGENESIS OF FETUS 


43 


Upon admission the fetus was presenting S.U.A. at the vulva, so delivery was 
done without further examination. A 2500 gm. fetus of good color was delivered 
which, however, did not attempt to breathe, rapidly became cyanotic and was pro- 
nounced dead ten minutes after delivery. Because of tlie appearance it was presumed 
that death occurred at, or shortly after the time of delivery, and not in utero. No 
amniotic fluid was noted at the time of delivery and the patient stated emphatically 
that none had been lost before or during labor although it was present in appreciable 
amounts in her three previous deliveries. The placenta was 10 cm. in diameter, and 
contained numerous infarcts. 

Postmortem examination demonstrated a well developed and well nourished fetus, 
49 cm. in length, weighing 2500 gm. There was an imperforate anus and the testicles 
were not in the scrotum. There were no abnormalities of the internal organs except 



Fig-. 2. — ^This represents a section taken from the fibrous mass on the sacral 
promontory. With considerable difficulty a field was found which contained a hypo- 
plastic glomerular body. Scattered fetal type tubules can be seen. 

those relating to the genitourinary system. In the position normally occupied by 
the kidneys were thin, brown kidney shaped organs weighing 4 and 5 gm. The blad- 
der was found to be a very small organ with a small collapsed cavity from the base 
of which extended a duct through the prostate to a small, irregular, firm gland-like 
structure situated on the sacral promontory, whicli proved to be undeveloped kidney 
tissue. The testicles, with epididymis and vas deferens, were lying free just above 
the brim of the pelvis. The inferior vena cava existed as two trunks continuing up- 
ward from the iliac veins. The right hypogastric artery was absent and the left 
common iliac which gives rise to the left hypogastric artery was larger tlian the 
right. The rectum terminated at the base of the bladder but did not communicate 
with it (Pig. 1). 

Microscopic examination revealed abnormal findings only in tlie lung, kidney re- 
mains and placenta. The lungs wore completely atelectatic with deposits of 
hematoidin throughout the alveoli. The kidney remains consisted of a fibrous mass 
interspersed with fetal type tubules and an occasional hjTioplastic glomerular body. 






BATES: BILATERAL RENAL AGENESIS OF FETUS 


45 


The bladder and prostate were not remarkable. The placenta showed an unusual 
amount of infarction and calcification, but no evidence of infection (Pigs. 2, 3, 4). 

In five of tlie cases presented in Table I we may assume that tbe caudal 
portion of tbe neplirogenic cord failed to develop metanepbrogenic tis- 
sue and coincidentally, no budding occurred at tbe lower end of tbe wolf- 
fian duet. In two cases ureteral budding did take place as evidenced 
by ureteral remains in tbe form of a fibrous cord in one and a small 
amount of eccentrically placed hypoplastic kidney tissue in tbe other. 
Tbe defect in development then bad its beginning at about tbe 5 mm. 
stage, or fourth week, at which time tbe mesonephros is most fully 
developed. 

In 1921 Huerzler described a fetus with complete absence of both kidneys as- 
sociated with oligohydramnios, and stated that search of the literature revealed 
only two similar cases, those of Hoenes and Hochsinger. However, Giles and 
Strassmann had each observed this condition and recorded a case previous to Hoenes 
and Hochsinger. 

Table I presents all reported eases of bilateral renal agenesis includ- 
ing tbe two studied by tbe writer. 


Table I. Total Eeported Cases op Complete Agenesis op Both Kidneys 


AUTHOR 

AGE 

SEX 

VIABILITY 
AT BIRTH 

LIQUOR 

AMNIl 

EXTRA URINARY 

ABNORMALITIES 

ANOMALIES OP 
URINARY TRACT 

Giles 

1892 

Term 

Male 

1 

Viable 

i 

No note 
made in 
case re- 
port 

Imperforate anus, 
malformed f e e t > 
rectum and bladder, 
absence rt. hypo- 
gastric artery, un- 
descended testes 

Absence both kid- 
neys and ureters 

i 

1 

Strassman 

1894 

8 mo. 
Male 

Viable 

^ None 

Bilateral club feet, 
undescended testes 

Absence both kid- 
neys and ureters 

Hoenes 1 

1895 

Term 

? 

Viable 

None 

Compressed cervical 
vertebrae, club feet, 
closure posterior 
fontanelle 

Absence both kid- 
neys, rt. ureter 
present as a cord 

Hochsinger 
1899 i 

Term i 

? I 

Viable 

None 

1 

Bilateral club feet, 
dislocation of both 
hips 

Absence both kid- 
neys and ureters 

Huerzeler 

1921 

Term 

Male 

Viable 1 

! 

1 

1 

None ! 

1 

Undescended testes 

Absence both kid- 
neys and ureters 

Author ’scase 
1930 

Term 

Male 

Viable 

None 

None 

Absence both kid- 
neys and ureters 

Author ’sense 
1930 

Term 

hlalo 

Vi.able 

None 

Imperforate anus, ab- 
sence rt. hypogas- 
tric artery, unde- 
seended testes, dou- 
ble inferior vena 
cava 

Absence both kid- 
neys. Small clump 
abnormal renal 
tissue on sacral 
promontory with 
duet to bladder 









46 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


In addition to the above are several cases of hypoplasia of the renal 
system so complete as to leave no doubt of the nonproduetion of urine. 
Academically they arc to be distinguished from the cases of complete 
agenesis but from their association with oligohydramnios cannot be dis- 
tinguished in considering the relation of fetal urine to the production of 
amniotic fluid. Table II outlines this anomalous condition and its as- 
sociated features. 


Table II. Reported Cases op Extensive Eekal Hypoplasia With 
Olioohydeamxios 


AUTHOR 

AGE 

SEX 

WABILPn 

AT BIRTH 

■ LIQUOR 
AJINII 

EXTRA URINARY 
ABNORMALITIES 

ANOMALIES OP 

URINARY TRACT 

Jaggard 

1894 

ITauch 

Term 

Male 

8 mo. 

Vi.ablc 

None 

No rectum. Imperfo- 
rate anus. Bilateral 
hip dislocation. Ab- 
sence It. sternocleido- 
mastoid muscle 

Absence left kid- 
ney and ureter. 
Small cystic rt. 
kidney, obstruct- 
ed rt. ureter, .and 
urethra 

190S 

Male 

Viable 

None 

Undcseended testes, 
double pcs piano 
valgus 

Bilateral kidney 
aplasia 

Walz 

1923 

8 mo. 

i 

No note 

None 

1 

Absence genitalia, clo- 
aca present. Left 
club foot, polydactil- 
ia, umbilical .artery 
continuous with aorta 

Both kidneys a 
clump of pinhead 
sized vesicles. No 
' urethra 

Bardram 

1930 

8 mo. 
JIale 

Viable 

None 

Club feet 

i 

1 

Absence rt. kidney 
and ureter. Lt. 
kidney enlarged, 
entirely cystic. 
Bladder pea 
sized, empty 

Bardram 

1930 

8 mo. 
Female 

Viable 

None 

Bicornatc uterus 

Kidneys low, small, 
hypoplastic. No 
It. ureter. Blad- 
der tin)’, empty 

Bardram 

1930 

8 mo, 
Male 

Viable 

None 

Aplasia left tibia, mi- 
cromeli.a left leg, one 
toe on left foot, spina 
bifid.a, imperforate 
anus, undescended 
testes 

Bilateral kidney 
aplasia 

Bardraai 

1930 

Smo. 

Male 

Viable 

None 



There are several observations of interest to be made on these two 
series as a whole, apart from the common urinary anomaly of the first 
group. Ten fetuses were males, one a female, in three this luiowledge of 
the sex could not be obtained, and all were at or near term; all were 
viable at birth save one (no note) but lived less than one hour ; in all but 
one there was a definite history of oligohydramnios, and in this ease the 







bates; bilateral renal agenesis of fetus 


47 


presence or absence of amniotic finid was not indicated; associated de- 
formities were malformed feet, malformed rectum and bladder, absence 
of rectum, imperforate anus, persistent cloaca, polydactilia, spina bifida, 
aplasia of the left tibia, bieornate uterus, compressed cervical vertebrae, 
closure of posterior fontanelle, dislocation of hips, undescended testes, 
and absence of the right hypogastric artery. In other cases of oligohy- 
dramnios, fracture and bending of long bones, and ichthyosis have also 
been observed. Some of these deformities, and many others such as 
harelip, are seen with normal and even excessive amounts of amniotic 
fluid, and Ahlfeld has even observed cases of ichthyosis with normal 
amounts of amniotic fluid. Certain of these deformities, as club foot, 
fracture and bending of long bones, compressed vertebrae, and possibly 
ichthyosis can be accounted for by mechanical influences following 
oligohydramnios. The others are developmental failures independent of 
the lack of amniotic fluid. From the fact that all fetuses were at or near 
term and viable at birth, it seems fair to assume that fetal kidneys play a 
negligible role in the physiology of the fetus, but by inference from the 
death of all fetuses shortly after birth, the kidneys must assume a major 
role immediately after being cut off from the maternal circulation, as do 
also the heart and lungs. 

These 14 eases of renal agenesis and hypoplasia associated with oligo- 
hydramnios are of great importance when one considers the question of 
the source of amniotic fluid, for proponents of the fetal urine theory look 
for their greatest support in those instances of oligohydramnios associ- 
ated with urinary anomalies. Considered alone these cases of complete 
renal agenesis, together with the cases of renal hypoplasia would seem to 
afford sound evidence in favor of this theory. There might also be added 
as evidence the fetus of Bertkau, full term, no amniotic fluid, and the 
urethra obstructed by a membrane which, when ruptured, allowed the 
escape of a half ounce of turbid urine; and Neumann’s case of sirenom- 
elus with renal agenesis and oligohydramnios. 

Polyhydramnios not infrequently occurs in unioval twin pregnancy, 
affecting only one amniotic sac, and in these cases it is difficult to escape 
the conclusion that fetal urine has to do -with overproduction of fluid. 
The twins as a rule differ markedly in size ; the heart and lungs of the 
larger twin are greatly hypertrophied; the polyhydramnios affects the 
amniotic sac of the larger twin, that of the smaller twin containing a nor- 
mal or a diminished quantity of the fluid. The umbilical vessels of uni- 
oval twins always anastomose freely in the single placenta and, if for 
some reason one twin obtains more than its fair share of the circulating 
blood, its heart and kidneys hypertrophy, wdth the result that the secre- 
tion of urine is greatly increased and polyhydramnios follows. Oppos- 
ing this observation are the cases of Benthin who found practically the 
same sized kidneys in certain unioval tvuns despite great differences in 
tlic quantity of amniotic fluid. However, a careful review of the litera- 



48 


ASIERICAN JOURNAL OF OBSTETRICS AND OYNECOLOGY 


ture by Schiller and Toll in 1927 shows but 57 reported eases of oligo- 
hydramnios of which only 15 present malformations of the urinary tract, 
many of these 15 showing neither complete renal aplasia nor obstruction 
to urinary outflow, such as Schiller and Toll's ease with left kidney and 
ureter absent, but right K'idney compcnsatorily enlarged and with double 
ureter. Then again, AYagiier has reported many cases of aplasia and 
atresia of the urinary system with normal and even excessive amounts of 
amniotie fluid. 

Schiltcr and Toll studied carcfullj' their case of oligohydramnios with an anomalous 
development of the urinary system, previously mentioned, and found a diffuse chronic 
inllammatorj" change witli infiltration of leucocytes in the placenta, amnion, and 
chorion. The amniotie epithelium was nowhere degenerated and showed on its fetal 
surface onl 3 ' cuboidal and fiattened forms which are described as normal for the 
middle of pregnancy. ITowcver, the vacuolated structure and drops of secretion 
which Forsell describes as characteristic for the normal amniotie surface, was no- 
where observed, and the conclusion is drawn that histologically no ground can be 
found for attributing a socrctor 3 ' activit 3 - to the peripheral amniotie epithelium in 
this case. The 3 ' believed that toxic products passing from the infected placenta di- 
rectly into the amniotie s.'ic must have altered the function of the secretory epithelium 
even if it did not destroy the epithelium, and o)i this basis explained the oligo- 
Ip'dramnios. In the cases presented by the author no evidence whatever could be 
found of infl.ammatory changes in placenta or membranes. 

That the oligohyclramiiios is not the cause of the renal agenesis is cer- 
tainly true, especially in the light of Ahlfeld’s statement that decrease 
or disappearance of the amniotie fluid takes place in the latter half of 
pregnancy, long after the embryologic defect has become manifest. That 
the oligohydramnios is the result of failure of adult functioning renal 
tissue to develop and not a coordinate phenomenon must remain a de- 
batable question. Tlie numerous cases of oligohydramnios nath normal 
kidne.vs is clear evidence that the.y are not the decisive element in the 
production of the amniotie fluid. This fact is further borne out by those 
cases with a normal amount of amniotie fluid despite malformations of 
the Icidueys or elosime of the urinaiy passages. These eases of kidnej’- 
malformations with normal amounts of amniotie fluid, on the one hand, 
and normal kidneys with oligohj^dramnios, on the other, speak against 
cause and effect, yet it is impossible to ignore the fact that 6 of the 7 
cases of complete renal agenesis and all 7 of the cases of renal hj’poplasia 
with absent renal function w'cre associated with oligohydramnios, and in 
the seventh case of the former series the record is incomplete. 

Further evidence from clinic.il observations to indicate a positive relationship be- 
tween fetal urine and the production of amniotie fluid is to be found in a stud 3 '’ b}’ 
Bardram. Me examined the postmortem records of nil the c.ases of kidney anomalies 
found in children, either stillborn or dying shortly after birth, and who were autop- 
sied at the Patliologieal-Anatomical Institute of Copenhagen from 1911 to 1929. 
This study was undertaken to see the relationship of kidney malformations in gen- 
eral to oligohydramnios. 



BATES; BILATERAL RENAL AGENESIS OF FETUS 


49 


He found : 7 cases of hypoplasia renum 

2 cases of unilateral polycystic kidney 

12 cases of bilateral polycystic kidney 
4 cases of horseshoe kidney 

12 cases of unilateral hydronephrosis 

13 cases of bilateral hydronephrosis 
2 cases of bilateral kidney aplasia 
8 eases of unilateral kidney aplasia 

By examining the hospital records of the births of these fetuses he found that 
oligohydramnios occurred in : 

100 per cent of the cases of bilateral kidney aplasia 

100 per cent of the cases of unilateral kidney aplasia with hypoplastic 

solitary kidney 

67 per cent of the cases of bilateral polycystic kidney 
43 per cent of the eases of hypoplasia renum 
0 per cent of the eases of unilateral kidney aplasia with normal 

solitary kidney 

0 per cent of the cases of unilateral polycystic kidney 
0 per cent of the cases of unilateral or bilateral hydronephrosis 

Bardram’s study together with the 14 eases reviewed in 'this paper cer- 
tainly make it reasonable to assume clinically, at least, that the fetal 
kidneys play some role in producing amniotic fluid though its exact 
nature is not yet Imown. 

Prom another quarter comes more recent evidence, adduced from ex- 
tensive physical and chemical studies of maternal blood serum, fetal 
urine and amniotic fluid, to give added weight to the inferences drawn 
from the clinical observations already discussed. Makepeace and co- 
workers were able to show that . . . at term the amniotic fluid 

is distinctly hypotonic to maternal serum, but in the earlier months 
of pregnancy this hypotonicity is less, and in the earliest months the 
amniotic fluid may be isotonic with maternal serum. Thus, early in preg- 
nancy the amniotic fluid approaches the composition of other protein free 
fluids which are in osmotic equilibrium with the blood plasma. This sug- 
gests that the amniotic fluid originates as a dialysate in equilibrium wth 
the maternal and fetal body fluids. The fetal urine is definitely hypo- 
tonic and is present in the bladder as early as the fourth month in preg- 
nancy. This indicates as pregnancy advances the amniotic fluid becomes 
more and more diluted by the hypotonic fetal urine. ’ ’ 

The relationship of fetal urine to the production of amniotic fluid is 
further implied by a consideration of the embryologic development of the 
Iddney in the light of observations made by three men. The metanephros 
or adult kidney is developed to tlie point of function somewhere between 
the third and fourth montli of embryonic life, iilakepeace was able to 
obtain urine from a fetus three to four months of age ; Zangmeister con- 
cluded that as early as the fifth month of pregnancy the amniotic fluid 
must 1)0 diluted with an appreciable amount of fetaf urine ; and Ahlfeld 
states that the disappearance of the anuiiotic fluid takes place in the lat- 



50 


ASIERICiVN JOURNAL OP OBSTETRICS AND GTNECOLOGY 


ter half of pregnancy. We may fairly assume that in the 14 cases pre- 
sented amniotic fluid was present early in pregnancy, before the fourth 
month. At this time the metanephros failed in development and no urine 
was formed, following which the production of amniotic fluid ceased. If 
amniotic fluid were entirely a transudate from maternal blood, or a se- 
cretion of the amniotic epithelium, one would expect some fluid to have 
been present at term. Therefore another factor must be necessary, 
namely the presence of secreted fetal urine. 

Schiller and Toll advance an enticing theory that the fetal Iddneys 
produce only small amounts of a highly concentrated urine which, acting 
as an irritant, stimulates the amniotic epithelium to secrete fluid of low 
concentration. This thcoi’y may well explain the cases of complete renal 
agenesis associated with oligohydramnios, and their own case in which 
placental infection ivith its related inhibition of secretory function of the 
amniotic epithelium is well established, but it is difficult to apply to those 
eases of oligoh 3 'dramnios in which no urinaiy anomaly occuiTed. How- 
ever, even in those cases there may have been a pathologic condition in 
mother, fetus, or placenta either unobserved or unreported which altered 
function of either the amniotic epithelium or the fetal Iddneys. Also, 
it is not incompatible ^vith the view of hlakepeaco that amniotic fluid is 
originally a dialysatc in equilibinum with maternal and fetal body fluids 
becoming more and more diluted by the definitely hypotonic fetal urine 
as pregnancj’’ advances. 

In conclusion it may be stated that oligohydramnios is rare ; complete 
renal agenesis is extremely rare, but is apparently always associated 
■with an absence of amniotic fluid ; fetal Iddneys plaj’- a negligible role in 
the plij’-siology of the fetus except as thej* maj’' relate to the production of 
amniotic fluid; and that these 7 cases of complete renal agenesis, 6 of 
which are associated definitelj’^ with oligohydramnios, together with 7 
cases of extensive renal hypoplasia and oligohjffiramnios, afford pre- 
sumptive evidence in favor of the ^'iew that there is a direct relationship 
between the production of fetal urine and the production of amniotic 
fluid. 

REFERENCES 

AhlfeU: Ztsclir. f. Gebiirtsh. u. Gyniik. 57: 67, 1906. Hem; 69: 91, 1911. 
Balard; Bev. mens, de Gynec. et d’Obst. 14: 187, 1919. Bardram, E.: Acta Obst. 
et Gynec. Scandinav. 10: 134, 1930. Benthin; Monatsebr. f. Geburtsli. n. Gynak. 
34: 567, 1914. Berfkau; Centralbl. f. Gynak. 45: 1099, 1921. Felix; Kibell and 
Mall, Human Embryology 2: 752, 1912. Forsell; Arch. f. Gynak. 96; 436, 1912. 
GUcs: Trans. London Obst. Soc. 34; 129, 1892. Eanch; (Quoted by Bardram) 
Hospitalstidende, 1908. Eiierseler, 0.: Centralbl. f. Gyniik. 45: 702, 1921. Eoch- 
singer, C.; 'Wien. med. Presse, Nr. 3, 1899. (Quoted by Huerzeler.) Eoenes, K.; 
Dissertation, Bonne, 1895. (Quoted by Huerzeler.) Jaggard; Am. J. Obst. 29: 
432, 1894. Makepeace, A. W., Frcmont-Smitli, F., Bailey, M. E., and Carroll, M. P.: 
Surg. Gynec. Obst. 53: 635, 1931. Neumann: Centralbl. f. Gyniik. 46: 1922. Strass- 
mann; Ztsebr. f. Geburtsb. u. Gyniik. 28; 1894. Toll, B. M., and Schiller, TV,; Ah. 

J. Obst. & Gynec. 13: 689, 1927. Wagner, A. G.; Beitr. z. Prage d. Herkumft. d. 
Pruchtwasser, Wien, 1913. Wals; Centralbl. f. Gyniik. 47 : 1435, 1923. Zangmeister, 
W., and Meissl, J. ; Miincben. med. Wchnschr. 1 : 673, 1903. 

955 PiSCHER BtriLDING. 



REPOET OP A CASE OP OVARIAN EMBRYOSIA* 

P. J. Sarma, M.D., M.Sc., P.A.C.S., Chicago, III. 

(From the Department of Surgery, University of Illinois College of Medicine and 

Jtavenswood Hospital) 

R eviewing the literature and our own cases I find that' ovarian 
emhryomas are not uncommon. 

The terminology used for the classification of this form of tumor is very 
confusing. It has been called emhryoma, teratoma, teratomatous, terato- 
blastoma, teratoid, dermoid, cystic and solid teratoma, mixed ceR tumor, 
benign and malignant teratoma by various writers. 

After an intensive study of this problem Willms^ concluded that the 
dermoid cyst and teratomas of the ovary are genetically similar. They 
both contain all three embryonic layers. It was he who suggested the 
simple and anatomically correct term cystic and solid embryoma. 

Out of 775 cases of ovarian tumors operated at the Ravenswood Hospital, 
fifteen cases of ovarian cystic emhryomas were found. These were all uni- 
lateral tumors. The largest tumor in this series weighed two pounds. The 
youngest patient was twenty-three years old, the oldest sixty-four. One 
case of ovarian cystic embryoma with twisted pedicle was operated as a 
surgical emergency. There were no malignancies in this group. 

Kroemer- found in his collected cases that thirty-four operations were 
performed with a primary mortality of 16 per cent. Out of 27 patients 
that recovered from operation, 16 or 59 per cent, died within the first or 
second year. Of 7 patients in this group that were considered cured, only 
5 could be followed for more than five years, giving a curability of 25 per 
cent. Doderlein^ gathered 51 cases in the literature. Twelve of this gi’oup 
were found well from six months to seven years after operation. He also 
found that only 4 cases were reported well after six to twenty-four years 
after surgical removal. Harris* collected 21 cases in the literature under 
the age of fourteen. The youngest girl of this group was under four. His 
own patient, five years and ten months of age, was found well ten years 
and eight months after operation. Eden and Locljyer= have gathered 16 
cases of solid embryoma. The oldest patient in their group was thirty 
years old. Black® operated on two patients with solid embryoma of the 
ovary, one patient remaining well after three years and the other showing 
no sign of recurrence after fourteen months’ observation. DeiMora’^ has 
reported a patient of nine years of age having a large right ovarian solid 
embryoma. This ease was operated by Gorst. There has been no recur- 
rence in eight months. 

lYillms* considered the solid embryomas as originally benign, only sec- 
ondarily showing malignant changes, Pfannenstiel,® Earing® and Boyd’® 

•Presented before the Chicago Gynecological Society, March IS, 1932. 

51 



52 


AJIERICAN JOTJRNAti OF OUS'nJTRICS AXD GYKECOLOGY 


feel that these tumors are mali'nmiit from tlic very beginning. Secondary 
involvement occurs fi-om the perforation of the capsule and implantation 
in the pelvis, peritoneum, dia])hragm and omentum. Histologically, solid 
embryomata present lawless growth of varieties of tissues derived from 
the ectoderm, endoderm and me.sodcrm. Though it is common to find 
mostly organs and structures of the cephalic portion, yet intestines, solid 
abdominal viscera, muscle, bone, cartilage, nerve, etc., are found. Some 
observers found that in this tjT^c of tumor the mesoblast gains ascendency. 

Studying the reported eases in the literature for some characteristic 
symptoms to aid in the diagnosis of this condition, one finds himself at a 
loss. The age of the patient and rapidity of the growth should always 



Pig. 1 , — First tumor under low power x52, solid embryoma. 


bring solid embryoma to mind for differential diagnosis. Premature pu- 
berty with precocious somatic development has been reported by few 
observers. 

Symptoms of pressure from the size of the tumor has been found in a 
majority of the cases. Ascites was usually present in young patients. 
Gardner^^ has pointed out that maliguant tumors arising in a solid em- 
bryoma are usually mixed, cai'cinoma, rhabdomyomas or sarcomas, etc., 
depending on Avhich elements partake in the malignant changes. 

Case Beport.—Jj. V., a girl, five years and four months old, was admitted under my 
care at the Eavenswood Hospital on January 7, 1930. Patient’s chief complaint was of 
a rapid growing abdominal enlargement. Examination revealed that she was a nor- 
mally developed girl whose past history was unessential except for a mild attack of 
measles when three years old. She had suffered from periodic attacks of vomiting since 



SARMA; OVARIAN EMBRYOAIA 


63 


childhood. These were generally brought on by nervous excitement. A presystolic 
murmur in the mitral region was present but the heart rvas otherwise normal. 

About six months before consulting me, the child’s mother noticed that the patient’s 
abdomen was growing large with great rapidity. Examination revealed a very decided 
enlargement of the whole abdomen and on palpating, a firm smooth mass was found 
which extended from the ensiform cartilage to the symphysis pubis, towards the left 
side. The mass was somewhat fluctuant but not movable from side to side. The ab- 
domen over the surface of the mass was dull to percussion. Pressure over the tumor 
elicited no tenderness but produced slight dyspnea. Absence of tympany over the ab- 
domen indicated that the mass was external to the intestines. Putting the patient in 
the knee-chest position and palpating in the back, the possibility of a retro- (extra-) 
peritoneal tumor was ruled out. A series of roentgenograms made elsewhere was of no 
diagnostic help. There were no genitourinary symptoms present. No rectal or vaginal 
examination was made. AVassermann negative; hemoglobin 53 per cent; erythrocytes 
4,160,000 ; leucocytes 16,000 ; small lymphocytes 21 per cent, polymorphonuclear neutro- 
phils 79 per cent. 



Fig. 2. — Same, under high power x320. 


A preoperative diagnosis of an ovarian tumor was made, though the location sug- 
gested a large cyst of the spleen which could not positively be ruled out without an 
exploration. 

On January 8, 1930, under ethylene and oxygen anesthesia, a left paramedian inci- 
sion with lateral retraction of the rectus muscle gave an excellent exposure of the tumor. 
The incision was four inches long and extended one and one-half inches above and two 
and one-half inches below the umbilicus. A large glistening tumor could be seen 
through the thin, almost transparent omentum. The multUoeular tumor was not ad- 
herent to any neighboring structures. It was easily identified as a left ovarian growth 
and was removed intact by ligating the long vascular pedicle. The opposite ovary and 
neighboring organs were found normal. The abdomen was closed in the usual waj', 
the operation lasting only forty minutes. 

Aside from a slight rise in pulse and temperature for the first forty-eight hours, the 
postoperative course was perfectly smooth. The stitches were removed on the eighth 
postoperative day and the wound healed by primary intention. The patient left the 
hospital on January 19, 1930, twelve days after operation, in perfect condition. Our 
pathologist. Dr. L. C. Alurphy, reported the pathologic findings of the tumor as follows: 

"The spechnen is a multilocular cystic tumor weighing 1370 grams (4.7 pounds) 
and measuring about 19 by 17 by 9 cm. The entire surface is smooth, glistening and in- 




54 


AJIERICAN JOURNAL. OF OCSTETmCS AND GYNECOLOGY 


t.iet. Many of the cysts form projecting knobs on the surface. Some of the externally 
situated cysts are partially filled with thin, amber colored fluid but the greater portion 
of the mass is composed of eompartinents filled with edematous yollowish-whitD honey- 
combed tissue with lobnlated appearance. In some compartments this tissue is firm and 
elastic while in otliers it is of a softer, semi-gelatinous consistency. Small calcified 
areas arc noted in the solid, white tissue in some of the compartments. The micro- 
scopic sections show the structure of a teratoma in which the following tissues are repre- 
sented: Cartilage, bone, museio, fat, glands, ovarian stroma, squamous epithelium.” 

The patient was kept under observation and was regularly examined every two weeks. 
The progress was found very satisfactory. Repeated abdominal palpation revealed no 
enlargement. On October 21, 1030, the patient was examined and showed very satis- 
factory results. 



Fig. 3. — Second tumor removed 0ec. 6, 1330, 5 pounds, anterior view. 

On November 20, following the last inoculation of diphtheria antitoxin at the public 
school, the patient developed vomiting, chills, and high fever. Though the fever sub- 
sided within three daj's, the mother noticed a fullness of the child ’s abdomen. Think- 
ing that it might be g.aseous distention she did not consult me until the twent 3 -ninth 
of November, exactlj' nine daj’s after the inoculation of the antitoxin. ^ The mother 
stated that ‘‘the abdomen grew larger everj* day.” I found the abdomin^ measure- 
ment showed a growth of five and. one-half inches in the level of the umhilicns since 
the last examination. The mass was smooth and firm in palpation. It was much 
harder than the first tumor. The tumor filled the whole abdomen and the exact rela- 
tion of it could not bo clearly outlined. General ex.amination indicated that the 
patient was in excellent condition for operation. The urine examination was n^atwe 
except for a very faint trace of albumin. Blood picture showed hemoglobin i5 per 
cent, erj’throcytes 4,220,000, leucocj'tes 11,750. 



sarma: ovarian embryoma 


55 


The patient enteTed the Eavenswood Hospital on Dec. 4, 1930, and was operated 
on under ethylene and ether on Dec. 5, 1930. The tumor was reached through the old 
scar. Some free bloody fluid was found on opening the abdomen. A large solid 
tumor filled the abdominal cavity. Its anterior part was attached to the greater 
omentum. This was easily ligated and separated. Three inches of ileum were at- 
tached to the posterior central part of the tumor. It was not possible to separate 



Pig. 4. — Second tumor under low power. Adenocarcinoma x52. 



Pig 5. — Same, high power x320. 

the intestine without entering the tumor tissue, so six inches of the ileum were re- 
sected. A lateral anastomosis established its continuity. The abdomen was closed 
after a careful survey of the neighboring structures. No pathology could be found 
in the right ovary. No metastases were visible or palpable. The operation lasted 
one hour and twenty minutes. 

The patient’s rectal temperature rose to 103° P. for six hours after the operation. 
There was a normal bowel movement on the third postoperative day. Convalescence 




56 


AJriCRICAN JOURNAL OP OBSTETRICS AND GTNECOLOGV 


wns uneventful. Sutures were removed on tlic eighth postoperative day. There was 
primary healing of the wound. The patient left the hospital in e-xcellcnt condition on 
the tenth postoperative day. The pathologic report hy Dr. Murphy was ns follows: 

“The specimen is a round, solid tumor nmss weighing five pounds. The external 
surface is smooth, of a dark mottled color with nodular irregular, bulging areas 
ranging in size from a walnut to an orange. The interior is composed of soft, 
edenmtons, yollon'ish-white tissue which becomes mottled with hemorrhage near the 
surface. Microscopic sections show practic.allj' the same structure as the tumor 
removed in January, 19.^0, viz., teratoma, except that in this second tumor there is a 
greater proportion of glandular epithelium indicating a more malignant structure 
(adenocarcinoma ) . ’ ’ 

Tho patient’s convalescence was s.atisfaclory for about throe months after the last 
operation. On JIarch 30, 19.31, fluid accumulation in the .abdomen was noticed. En- 
I.argement of the right cervical glands was present. The patient became quite anomic 
and mnrkedl}' debilitated. The intraabdominal fluid grew rapidly and it was neces- 
sary to remove one g.allon of it, on M.ay 14, 19.31, to relieve respiratory embarrassment. 
Large abdominal m.oss, and the enlargement of tho liver could be palpated at this 
time. The patient grew weaker and died on May 21, 1931. 

Autopsy was refused. 

Summary and Conclusion. — 3. Ovarian einbryomas are subdivided in- 
to cystic and solid tj^ics on anatomic grounds by 'W'illms. This is the least 
confusing terminology. 

2. Tlie cystic embryoma is a common form of ovarian neoplasm. In a 
series of 775 ovarian tumors at the Ravenstvood Hospital, 15 vere cystic 
embryomas. This is a much lower percentage than found in other clinics. 

3. The solid embiyoma is a very rare ovarian tumor. It is malignant 
from the very beginning. A case of this tj’pc is reported in a girl of five 
yeai’s and four months of age. The tumor occurred in the left ovary and 
weighed 4.7 pounds. This was removed intact -without difiSculty. It re- 
curred after eleven months. The tumor grew rapidly and filled the ab- 
domen within nine days. Operation revealed a fi^'e-pound tumor originat- 
ing in the greater omentum. The close adhesion to the ileum required a re- 
section of six inches of the bowel. A lateral anastomosis established the 
continuity of the intestine. Postoperative reeoveiy was satisfactory. The 
patient died -within six months after the last operation from I’ecurrenee 
and metastasis. 

4. Every solid embiyoma should be considered potentially malignant. 
The study of the literature impresses the necessity of prophylactic removal 
of all ovarian cysts in toto. 

REFERENCES 

(1) Willms, V.: (a) Deutsche. Arch. f. Klin. Med. 55: 1S95. (b) Martin’s Hand- 

buch -D-. S. "W. Ziegler ’s Beitr. z. Path. An. u. Allg. Path. 19: 1896 ;M. f. G. u. G. 9: 1899. 
(c) Arch. f. Gyniik. 61; 203, 1900. (2) Erocmer, P.: Handbuch der GynUk. 1908, 4, 
first half, 213. (3) DoderJein, A. : Die KHnik der bosartigen Geschwiilste, 3 : 111, 1927. 

(4) Harris, S. H. : (a) Surg. Gynee. Obst. 604, 1917. (b) Surg. Gynee. Obst. 191, 1925. 

(5) Ede», T. W., and Lochyer, C.; The New System of Gjmecology, Macmillan, London 

2; 787-800, 1917. {5)Blaoh, IFm. T.: Am. J. Obst. & Gtnec. 10: 345, 1925. (7) 
DeMora, J. L. E.: Les Tumeurs Solides de L’Ovaire, 6. Doin, eie, Paris, 1931. (8) 
Pfannensticl, J.; Veits Handbuch d. Gynak. Wiesbaden, 1908. (9) Exoing, J.: 

Neoplastic Diseases, W. B. Saunders Co., ed. 3, p. 613. (10) Boyd, W.: Surgical 

Pathology, W. B. Saunders Co., 1925, 216, 524. (11) Gardner, 0. E.: Lewis Prac- 

tice of Surgery, Prior Company, ch. 27, pp. 56-62. 



SAKMA: OVARIAK EMBRYOMA 


57 


DISCUSSION 

DE. LYMAN C. MUEPHY. — I have seen two instances in which microscopic sec- 
tions were made and a report given that no evidence of malignancy was found. In 
one case the pathologist even suggested a favorable prognosis and did not think x-ray 
was necessary. Both patients were dead within one year. 

DE. IRVING P. STEIN. — The point brought out in reference to the malignancy of 
embryomas is important. The essayist said that they had had no experience with x-ray 
in the diagnosis of these tumors. I feel that they have missed something vital in the 
diagnosis. The large tumors, whether they be teratomas or cysts, indicate surgery 
from the size alone. The small growth from 2 to 4 cm. in diameter are very impor- 
tant from the standpoint of preoperative diagnosis and from the standpoint of whether 
or not they are to be attacked surgically. Our experience with the use of pneumo- 
peritoneum in diagnosis is that we can detect many small ovarian tumors quite early 
and can differentiate various types of ovaiuan swellings by x-ray. Simple cysts, par- 
ovarian cysts and dermoids are readOy distinguished, the latter by the presence of 
teeth, bone or smaU areas of calcification. Vfe have shown that ovarian pathology can 
be visualized on the roentgenogram after pneumoperitoneum and thus determine 
whether operation shall or shall not be done. 

DR. N. S. HEANEY. — Solid embryomas are so rare that single case reports are of 
the utmost importance. The condition of the remaining ovary at the time of the sec- 
ond operation in Dr. Sarma’s case should be very definitely stated. Ovarian tumors 
are very frequently bilateral and when a patient has been operated upon for a tumor 
of one ovary and subsequently has to be operated upon for a second tumor the prob- 
abilities always are that the second ovary is also the seat of a tumor. 

One point in the treatment of dermoids that I consider of some importance is that 
when one ovary is operated upon for a dermoid cyst the opposite ovary, though normal 
in appearance, should be carefullj' slit and inspected for the presence of a possible 
dermoid. If this is done one may occasionally find a dermoid no larger than a pea 
or bean which may be easily removed and prevent an operation at some future time 
when it has grown big enough to produce symptoms. 

DE. deTAENOWSKY then stated that the right ovary wixs entirely normal, there 
was no pathology in the pelvis. He continued ; The thing that puzzled us was to find 
out how there had been an implantation. At the first operation the original tumor was 
free of all adhesions. It w-as lifted outside mthout rupturing any of the cysts and 
was clamped without any difficulty at all and we could not see any signs of implanta- 
tion anywhere. The child was normal aE these months so that we felt that we had 
removed everything, and then she had this relapse. Hoivever, the opposite ovary had 
nothing to do with the second growth. 

DE. ARTHUR H. CURTIS. — Do you not believe, in view of the serious prognosis, 
that it would usually be wise to give deep x-ray therapy to take care of the other 
ovaiy? 

DE. DeTAENOWSKY. — T hat is a good suggestion. 

DE. EEEDEEICK BALLS. — I would Eke to recount a few interesting tumors of 
this type that I have encountered. The first was a large demoid cyst in the pelvis of a 
woman on the medical service of the University of Iowa, who had entered with a diag- 
nosis of chronic rheumatism. The medical men could not find any focus of infection, 
e.vcept a mass in the lower abdomen which they took to be a pelvic abscess. This mass 
was opened and drained in July. Two months later the woman was still dr ainin g from 
the ovarian cyst and when I took over the service they told me there was a peculiar 
drainage from the vagina. We found on examining the vagina carefully that the in- 
terior of the cyst was full of maggots. During the hot summer flies had gotten in the 



58 


A5IEIUCAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


vagina and laid their eggs in this cyst. Since it was necessary to remove this dermoid, 
I took cultures from the cyst and found .streptococci, staphylococci and colon bacilli. 
The woman was not a good surgical risk .and yet because of the persistent discharge 
something had to bo done to relieve her. Wo irrigated the cyst from the vagina 
thoroughly ivith weak iodine solution over a period of two weeks and reduced the num- 
ber of bacteria. Wo then removed the cyst wall abdomiuall}'. After a rather stormy 
convalescence she recovered. 

About three months ago a nurse, nineteen years old, was found to have a tumor about 
the size of a fist in the region of the ovary. I felt it should bo investigated with the 
possibility that it might be a teratoma. She did not respond to the suggestion at once. 
Three weeks later the tumor was about twice the original size. I insisted that it should 
be removed at once and this was done. Wo found a teratoma. Feeling that, when we 
aro dealing with a malignant tumor of tho ovary, it is tho general rule that the other 
ovary and uterus bo removed, I removed the ovary and uterus from this girl. 

About two years ago at the Research Hospital a girl about sixteen years of age was 
sent in with this history. Slio noticed a swelling of the abdomen. She told her mother 
about this and her mother took her to the family doctor who considered the possibility 
of a pregnancy. An x-ray picture -was taken by a local dentist who said that tho girl 
was pregnant. Tho father of this girl, on learning this, sent her to a reform school. 
The doctor in charge of this school looked her over and watched her for a month or 
two. The abdomen was growing about the rate a pregnancy would, but the heart tones 
could not bo heard. The patient w.as then sent to the Rese.'irch Hospital where we made 
a diagnosis of teratoma and found this at operation. 

At the County Hospital about four yc.ars ago Dr. Schmitz did a hysterectomy with a 
right salpingo-oophorcctomy. He did not remove the left ovary. Six months later 
the woman came in with a tumor in tho region of the left ovary. I made a diagnosis 
of simple cj’st, opened the abdomen and found a teratoma. Within six months after 
leaving in what .appeared to be a normal ovary there had developed a teratoma. 

Three years ago I took out a large cyst in an cightcen-yc.ar-old girl. This was a 
very rapidly growing cyst and proved to be a teratoma. All of these cases were 
malignant. 


KRAUROSIS VULVAE, WITH A REPORT OP THIRTEEN CASES 
M. A. Goldberqer, M.D., P.A.C.S., New York, N. Y. 

{From the Gynecological Service and Division of Lahoratorics of the Mount Sinai 

Hospital) 

K raurosis is an atrophy of the tnilva due to changes in the epi- 
thelial and subepithelial elements of the skin. It usually occurs in 
women past the menopause, but may occur in young women. Its etiology 
is not well understood. Lack of ovarian hormone is considered a factor 
because it usuallj^ occurs in the seniium and there have been several 
reports claiming good results following the administration of female 
sex hormone. In the cases here presented, female sex hormone gave 
temporary relief in a very few instances and in no case changed the 
clinical or local condition. Prom this it maj’’ be inferred that the female 
sex hormone is not the important factor. Furthermore, while this 
disease is not rare, its incidence is verj’’ low even among the women who 
are past the climacteric. It is possible that an endocrine factor is the 



GOL.DBEKGER : KRAUROSIS VULVAE 


59 



Fig. 1. — Marked acanthosis and heaping up of the keratin layer. Eleiden granules 
stain deeply and connective tissue shows chronic inflammation. 



2. Ijahia^ majora are flattened out and the labia minora have comnletelv dis- 
appeared. The clitoris and prepuce are shrunken and the vulval orifice contracted so 
pefrly white.^ appearance of thin pa?clim ™nd Is 


60 


ASfERlCAN .lOURNAL OF OBS'l'ETRICS AND GYNECOI.OGY 


cause, but the proper one lias as yet not been determined. Veit believes 
that kraurosis is of inflammatory origin of long standing. 

In the last decade, cancer prevention and early recognition have re- 
ceived widespread interest. Carcinoma of the vulva comprises 4 per 
cent of all earcinoma of the genital tract. Berkeley and Bonney state 
that the relationship born by Icucoplakic vulvitis to carcinoma is closer 
than that of any other pathologic lesion with the exception of roentgen 
ra.v dermatitis. 

The clinical and histologic picture of kraurosis vulvac is a typical 
one. Early in the disease (Taussig’s first stage) the vulva appears swol- 
len and reddened (kraurosis rouge of Jayle). Histologically, there is 
a pronounced acanthosis, an increased keratosis and an infiltration with 



Fie. 3. — Low epithelial layer. Papillary processes are absent, eleiden granules 
sparse, connective tissue densely collagenou.s, and there are islands of round cetlea 
infiltration. 

I’ound cells and leucocytes. The second stage usually begins about one 
year after the initial appearance of the disease. The skin becomes white 
and firm and there may be excoriations from scratching. Blicroscopically 
(Fig. 1), there is still a marlvcd acanthosis and heaping up of the keratin 
layer. The eleiden granules stain deeplj', the connective tissue shows 
chronic infiammation vrith scattered areas of collagen and numerous 
plasma cells. This is called the progressive stage by Szasz and Veit. 
In the third stage (Fig. 2), the labia majora flatten out, the labia minora 
completely disappear, the clitoris and prepuce are shrimken and the 
vulval orifice contracts so that it barely admits the finger tip. The skin 
assumes the appearance of thin parchment, is pearly white, dry and 
cracks easily. This condition may at times involve only one area of a 
labium or be unilateral. The microscopic picture (Figs. 3 and 4), shows 




GOLDBERGER: KRAUROSIS VULVAE 


61 


a low epithelial layer. The papillary processes are absent, eleiden gran- 
ules are sparse, the connective tissue is densely collagenous and there 
are islands of round cells. The elastic tissue (Fig. 5), is decreased in 



Fig. 4. — ^Higher power of Fig. 3 showing densely collagenous connective tissue. 



Fig. B. Eiastic tissue stain showing elastic tissue broken 

of twigs. 


up and arranged as bundles 


62 


AMERICAN JOURNAIi OF OBSTETRICS AND GYNECOLOGY 


amount and appears broken up and arranged as bundles of twigs. 
Tins stage of kraurosis corresponds to what Szasz calls kraurosis sensu 
strictori. 

The most common symptoms that finally influence a patient to seek- 
relief are pruritus and dyspareunia. Dysuria and frequency may also 
occur. These symptoms should be differentiated from other causes such 
as parasitic diseases of the vulva, diabetes, dermatologic lesions, and 
psychoneurosis. 

The tabulated results of treatment of the thirteen cases of Icraurosis 
vulvae studied may be divided into two groups (Table I). In Group I, 
there are five cases gathered from the out-patient and radiotherapy de- 
partments. They are all parous women past the fourth decade of life. 
Only one of these was still menstruating. In each case the symptoms 
and vulval lesions were characteristic of kraurosis. In three eases, low 
voltage x-ray was used without relief. In one, the Kromayer lamp was 
used, but tlie full coui’sc of treatments was not completed as the patient 
failed to return. Three of these patients received ovarian hormone, in 
the form of amniotin pessaries. In one, four suppositories a day were 
given over a period of tw'o and one-half months without improvement. 

In Group II (Table II), there are eight cases of la’aurosis \Tilvae, 
in all of whom vulveetomj- was finally’- done. Their ages ranged from 
twenty-nine to sixty-five. The twenty-niue-year-old woman had never 
menstruated and showed no sex hormone cycle in her blood. The thirty- 
cight-yeai'-old patient had a hysterectomy performed four yeai'S before. 
Of these cases only’- one was sterile, tlie patient with the primary amenor- 
rhea. They’- all complained of prui'itus and in three dyspareunia w-as 
the chief complaint. Female sex hormone or x-ray, or both were used 
in all eases but one. In every instance, the results were poor. At best, 
these patients had temporary’- relief, but in no case was there any^ effect 
on the local condition. In one patient, no previous treatment had been 
given as it was deemed inadvisable to temporize because of the marked 
Assuring of the Icraurotic skin. It is this case that shows a very eaily’ 
earcinoma -n’ilh kraurosis in the hy^perplastic phase (Fig. 6). Six blocks 
cut one-eighth inch in thickness, adjacent to that showing malignancy-, 
failed to demonstrate the eai'cinoma. This emphasizes the importance 
of cutting many blocks from a kraurotie vulva specimen submitted for 
examination. The eighth ease had a superimposed eczema of the 
■vulva which masked the kraurotie appearance of the skin. The ki'aurosis 
became evident after local treatment for the eczema. Here also the 
microscopic finding of an early carcinoma on a kraurotie basis w’as 
unexpected. The results in 6 of the patients in Group II were most 
striking following "vulvectomy. Five are cured for from three to five 
years. The sixth and eighth case have recently been operated. The 
seventh case, in whom there is a recurrence, was a private patient, not 
on the service of the hospital. 



Table I. Nonoperated Cases 


GOLDBERGER: KRAUROSIS VULVAE 


63 




64 


AMEinCAN JOURKjM, OF OBSTOTRIGS AND GYNECOLOGY 






































goldberger: kraurosis vulvae 


65 


Taussig, in Ms analysis of 76 cases of carcinoma of the vulva, found 
that 39 were on a kraurotic basis, 60 i^er cent being in the leucoplalde 
stage and 40 per cent in the atrophic stage. In other words, about 50 
per cent in his series showed kraurosis in eitlier stage. 

The microscopic slides and clinical description of 13 cases of carcinoma 
of the vulva from Mount Sinai Hospital have been studied. In 7 there 



Fig:. 6. — Early carcinoma, pearl formation and infiltration of connective tissue in a 

hyperplastic kraurotic lesion. 


Fig 



— Advanced carcinoma in a kraurosis in the atrophic pliase 
tarns areas of kraurosis in hyperplastic phase. ’ 


Same lesion con- 



66 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


ivas a coexisting kraurotie process (Pig. 7). Tiiey could not be grouped 
in tlje hyperplastic or atrophic stage because most of them showed both 
stages in the same specimen. The percentage of kraurosis in the car- 
cinomas of the vulva studied corresponds to Taussig’s figure of 50 
per cent. This high pei'ccntage of carcinoma associated with kraurosis 
and the poor results with medical and physical therapy leads to the con- 
clusion that the method of treatment should be vulvectomy. Brettauer, 
Prank, Taussig, and many others have stressed the importance of 
AUilvectomy for prompt relief and cure of kraurosis vulvae. It is here 
further emphasized that to eui’c kraurosis vulvae and forestall car- 
cinoma, vulvectomy should be done. 

SUMMARY AND CONCLUSIONS 

1. Thirteen cases of kraurosis vulvae ai’c analyzed, of which 8 were 
treated bj’- vulvectomy. 

2. Thirteen eases of carcinoma were studied in order to detennine 
a relationship to kraurosis. 

3. Both from the literature and this analysis, carcinoma was found 
to develop in kraurosis in 50 per cent of the eases. 

4. Unsuspected carcinoma was present in 2 of the 8 eases treated by 
vulvectomy. 

5. X-ray and hormonal therapy is inefiiective. 

6. Vulvectomy is the treatment for cure of kraurosis and prevention 
of carcinoma. 


REFERENCES 

(1) Barsony, J.: J. Gyogvaszat G8: 7S9-797, Oct. 6, 1929. (2) BcrJicJcy, C., 

and Bouncy, V.; Proc. Poy. Soc. Jted. 3: 29-51, 1909-1910. (3) Breishy: Ztsehr. 

f. Heilk. 29: 1885. (4) Brettauer, J.; Am. Gynec. & Obst. J. 15: No. 2, 1899. (5) 

Bttilin, E. T,: Brit. M. J. 2: Gl, C2, 1900. (C) ConnscUcr, V. S.: Minnesota Med. 

14: 312-318, 1931. (7) Flcisclmann ; Frng. Med. 'W’cbnschr. No. 36, 1886. (8) 

FranJs, Jl. T.: Gynec. & Obstot.-Patb. Monograph, 1922. (9) Friehocs, IT..- Derniat. 

Ztsehr. 55: 345-355, 1929. (10) Graves and Smith: J. A. M. A. 92: 1244, 1929. 

(11) Jadassohn : Cor.-Bl. f. schweiz. Aerzto 49: 453, 1919. (12) Jaylc: Pev. de 

gynec. et do chir. abd. 10: 633, 1906; IIcv. franc, de gynoe. ct d’obstet. 16: 193, 
i921. (13) Mueller, S. C.: Proc. Staff Meet. Mayo Clin., 6-5-9, Jan. 1931. (14) 

Bnitschler, C. B.; Ann. Surg. 89: 709-730, 1929. (15) Bosenfeld, W.; 

Monatsehr. f. Geburtsh. u. Gynak. 37: 13, 1913. (16) FoscnstcUi: Slonatsehr. f. 

Geburtsh. u. Gyniik. 15: No. 2* 1902. (17) Solrc, Casas, and Carranca; Leucopl.ape 
et Kraurosis Vulvaries, Paris, Masson & Cie, 1928. (IS) Schicheies : Arcli. f. Gynak. 
97: 409, 1912. (19) Sease, Euyo: Monatsebr. f. Geburtsh. u. Gyniik. 1903. (20) 

Taxissig, F. J.: Arch. Dermat. & Syph. 21: 431-445, 1930. (21) Thibicryo; Ann. 

do derniat. et syph. 9: 1-17, 1908. (22) Veit, J.; Handb. der Gyniik. 4: 611, 1910. 

145 West 86th Steeet. 



ON THE SUPPORTS OP THE UTERUS 
Harry Koster, M.D., P.A.C.S., Brooklyn, N. Y. 

A CRITICAL review of tlie value of the ligaments as supporting struc- 
tures to the uterus must result in the conclusion that they cannot 
be very effectual. This is especially true of the rormd ligaments, because 
at laparotomy it is seen that the uterus can easily be retroverted without 
any strain on the former and that the return of the uterus to its normal 
position upon the release of the retroverting strain is not due to their 
pull. This was well demonstrated in experiments performed by Maeken- 
rodt^ in which he resected a piece of both round ligaments near their at- 
tachment to the uterus in a manner to prevent the subsequent union of 
the separated muscular ends. He then retroverted the uterus and packed 
the intestines on its anterior surface, after which the abdomen was quickly 
closed. When the uneventfully recovered patient was discharged, he 
found that the uterus Avas in a normal position, even though during the 
convalescence the patient had been lying on her back, and of course, no 
longer had an intact round ligament to hold the uterus upAvard. The 
history of the end-result of round ligament operations for the cure of 
prolapse is also eloquent testimony of the ineffectiveness of these struc- 
tures to support the uterus. The peritoneal folds forming the broad 
ligaments, because of their A^ery structure, are not Avorthy of any consid- 
eration as uterine supports. The uterosaeral ligaments composed of ma- 
terial similar to the round ligaments are of no more value as supporting 
structures than are the round ligaments. The only other structure pos- 
sibly capable of supporting the uterus is the uteropelvic ligament, the 
Mackenrodt ligament, the cardinal ligament, or the infundibulopelvic lig- 
ament, as this structure has been variously called. Mackenrodt, in the 
examination of the fascia endopehuna (that portion lying over the 
levator ani and direetlj’- under the peritoneum) in a neAvborn, reported 
thick, bandlike fibers running directly to the vagina, rectum, and blad- 
der in which Avere muscular elements. Dorsally, he found a mass of these 
fibers arranged like a band in the border of the broad ligament, but 
distinctly separate from it, running from the pelvic fascia into the cervix. 
This he designated the ligamentum transversum colli, and claimed for 
it the sole support of the uterus. According to him, in the fetus and neAV- 
born, it runs from near the last lumbar vertebra doAvuAvard toAA'ard the 
side Avail of the cerAux to Avhich it is attached. As the ilia develop, the 
ligament moves farther aAvay laterally from the vertebral column, until 
it finally comes to lie in the transverse diameter of the pelvis. At its up- 
per border runs the uterine artery. 

He also described other bands of musculofascial fibers. One set of 
these forms the uterosaeral ligaments and the other set the pubovesico- 

67 



68 


A:iIEniCAK JOURNAL 07^ OBSTETRICS AND GYNECOI.OGY 


uterine ligaments wliieli latter run from the attachment of the ligamcntum 
transvoi-snm eolli to tlie cervix along tlie side vail of tlie bladder to the 
hind wall of the symphysis. Still other bands imn out into the recto- 
vaginal and vesicovaginal scptae, ofToring strong supports to the rectum 
and bladder and sei'ving lo close the pelvic floor aperture. All of these 
bands ai'c attached through the ligamenlnm transversum eolli to the 
uterus which is the pivotal supporting structure. These bands hold up 
tlm bladder and other pelvic organs. 

These statements have been acce])ted for face value quite generally 
without being corroborated by investigation. 

The adoption of original contributions as the fundamental basis for 
further work without research into the former for confirmation has been 
one of the greate.st obstacles scientific progress has had to contend with. 

In this instance the adojition of IMackenrodt ’s view has resulted not 
only in the development of a nomenclature but also in the elaboration of 
h>q)otheses regarding the mechanism of pi-olapsc, cystoeelc, and reetocelc. 
Many operations were developed for the cure of those conditions, adopting 
as fundamental, the existence of these ligaments and fascia as Mackem’odt 
described them. Thus it is quite connnon to hear operators speak of 
“operations for the correction of prolapse, cystocele, and rectocelc, in- 
cluding the jilication of rectovaginal fascia, vesicovaginal fascia, ‘Mack- 
enrodt's’ ligaments, etc.’’ 

In 1910 Blair BelP tanglit that the pelvic fa.<!cin instead of being a very compli- 
cated structure with a great many divertieuli .aeecssory to tlie main portion, consisted 
of simply a fibrous tissue investurc forming the sheath of and giving attachment to, 
the various muscles of the pelvic floor. Unfortunately however, his teachings did not 
receive the wide recognition that they deserved. Quoting from him, “Care must be 
taken that the separation is effeeted in the plane between the bladder wall .and the 
muscle and fascia underlying the vaginal mucosa, not only in order that the scp.aration 
may be ca.sy but .also that the muscle and fascia may bo sutured together subse- 
quently,” This appe.ars in tlio discussion on the technic of anterior colporrh.aphy. 
Spaulding' in the Ajieuican JourtNAU of Obstetrics and Gynecology, writing on 
hemostasis in vaginal liystcrectomy presents photomicrographs of tissue between the 
bladder and anterior wall of tlie vagina, in wJiieh he very definitely speaks of <a vesico- 
vaginal fascia. 

Eeeently Goff,' in an histologic study of the perivaginal fascia in a nullipara con- 
cludes that (1) there is no fascia of any kind in the walls of the vagina, urethra, blad- 
der, or rectum; (2) there is no fascia between the anterior vaginal wall and the 
urethral wall; (.3) there is n loose areolar tascia between the vagina and bladder and 
between the vagina and rectum not disseetable as a distinct layer; (4) this is tlio 
only fascia available to accord with the descriptions of fasci.a used in various operative 
procedures for the cure of cystocele and reetocelc; (5) this “faseia” is not .at all 
comparable with the dense faseia such as forms the slicath of the rectus abdominis. 

In Goff's very interesting article, he states that a careful search through 
the literature had failed to reveal any previous attempt at a study of a 
similiar nature with the exception of that by Spaulding on sections from 
the vesicovaginal septum in which tlie latter failed to state wliether the 



KOSTER: ON SUPPORTS OF UTERUS 


69 


subject from, whom the material was taken was nulliparous or multip- 
arous. It would seem that the more important point to make was that 
Spaulding disagreed with Goff’s findings, inasmuch as he stated very 
definitely that there was a vesicovaginal fascia of a well defined character 
which he utilized in the performance of a certain portion of the operation 
of vaginal hysterectomy. To us it seems that the question of multipara 
or nullipara is of importance in the direction opposite to that taken by 
Goff, inasmucli as the practical value of any fascia in the vesicovaginal or 
rectovaginal septum, if such existed, Avould be found in its utilization in 
operations in multiparous Avomen for repair of pelvic floor injuries. In 
other Avords if there AAms anj’- such fascia existent, it Avould be much more 
important to find this in a multiiAarous individual AAdio needed perineal 
reparative AA’ork than in a nulliparous AA'oman AA'ho needed no operative 
procedure. 



Fig. 1.— -Fibrous tissue along the junction of cervix and uterine body in which 
IS Seen a longitudinal section of the uterine vein and a cross-section of the 
uterine artery just before it turns to course along side of the uterus. There is 
no ligamentous or fascial structure in this loose areolar connective tissue. 

Dougal BisselP in an article entitled “Fascial lapping as applied to the 
tissues of the A’aginal AA'all, a misnomer” states that in cases of Amginal 
prolapse there is no definite fascial layer of the vaginal Avail AAdiich can 
be isolated and used surgically to advantage. He presents photomicro- 
giaphs of a section of tissue remoA'^ed from the left side of the anterior 
vaginal Avail. His conclusions are open to the criticism that tlie section 
of tissue Avhich he examined Avas not a complete section of the vesico- 
A’aginal septum and that in the tissue remaining in the septum and not 
excised for examination, fascial tissue might haA^e existed. 

In oui studies on the mechanism of the deA’elojnuent of pro]a2ise, among 
othei things, aa'c examined the structure of the A'^esicoArnginal and recto- 
A'agiual septa. 

i\ricroscopic examination of sections of the vesicovaginal septum and the 
lecfoA^aginal septum in autopsy material in a multiparous Avoman. shoAA-ed 
no evidence of existence of any fa.scial structure comparable to that de- 



70 


AIMERICAK JOUnxAI. OF OBSTETRICS AXD GYNECOLOGY 


scribed in any of the texts, in otlicr ivords our findings are in thorough 
accord with ilie findings of Goff in liis miI!iparous material. In our opera- 
tive material we have never been able to demonstrate any fascia in the 
reetovaginai or vesicovaginal septa. The only tissue to be found there, 
other than the mucosa is a loose, areolar connective tissue which can have 
no restraining or supportive value. 'Where then are those dense musculo- 
fibrons bands coming from the attachment of the ligamenfum transversum 
colli or nteropelvic ligament as others call it, and spreading out through 
the vesieoi'aginal and rectovaginal septi of which Jlaekenrodt wrote? 

In a similar set of studies made on autopsy material we investigated the 
tissue around the uterine arteries in their course from the internal iliac 
to the uterus in search for the so-called JIackenrodt ligament, and here 
again we met with negative results. 



Pig. 2. — Cro.'js section of the uterine artery, a longitudinal section of the 
uterine vein and a cross-section of two of its larger tributaries, and also a cross- 
section of the ureter wich surrounding loose areolar connective tissue but no 
ligamentous or fascial tissue. 


JIETHO0 

The uterus, adnexa, bladder, vagina, and urethra and all the loose areolar connec- 
tive tissue malcing up the parametrium ■were excised from a multiparous female pa- 
tient, thirtj'-one years of age with no .sign of prolajise or retrodispiaeement of the 
uterus, and the entire mass was fixed in formalin for a week. Then sections were 
made of the rectovaginal septum and the vesicovaginal septum. A section was made 
longitudinally parallel to the uterine artery as it coursed along the uterus, beginning 
at the round ligament and extending downward as far .as the junction of the vagina 
with the cervix, taking in a portion of the bladder wall and making a transsection 
through the uterine .artery .after it h.ad curved aw.ay from the uterus out tonard the 
lateral pelvic wall. Tliis section contained all the loose cellular and fibrous tissue 
around the junction of the cervix in the body and should have included the so-called 
Maekenrodt ligament. Other sections were then taken lateral to this one at dist.ances 
of V 2 om. tr.ansversely across the uterine artery and all its surrounding cellular and 
fibrous tissue, so that any ligament running from the uterus toward the lateral pelvic 
wall would be caught and transsected by these sections. Similar sections uere also 



KOSTER: ON SUPPORTS OF UTERUS 


71 


taken from operating room material after operations of complete hj’sterectomy. All 
of these sections were stained by the Van Gieson differential method (by means of 
^yhich fibrous and muscle tissue are easily distinguished). 

In the section of the rectovaginal septum, beginning at the upper end and running 
down to tlie perineum, the vaginal wall is separated from the rectum only by loose 
areolar connective tissue. Nowhere in this septum was there any fascial tissue. 

In the section through the vesicovaginal septum in the median line, the wall of the 
bladder is separated from the cervix and vagina by a loose areolar connective tissue 
in which nerve bundles and blood vessels can be seen, but there is no evidence of any 
fascia. Since these findings offer nothing new but are merely confirmatory of Goff’s 
results no illustrations are presented. 

Pig. 1 shows the tissue in a longitudinal section of the left side of the uterine artery 
as it courses along the uterus. Here can be seen the cellular and fibrous tissue along 
the junction of the cervix and body, a longitudinal portion of the uterine vein and a 
cross-section of the nterine artery just as it turns up to course along side of the uterus. 



Fig'. 3. — Ureter, uterine artery and vein in cross-sections embedded in 
loose areolar tissue. 

Tliese vessels are surrounded by a loose areolar connective tissue with no sign of a 
distinct fascial or ligamentous structure. 

Fig. 2 taken from a section 1 cm. lateral to the previous figure shows a cross-section 
of the uterine aj'tery, a longitudinal section of the uterine vein and a cross-section 
of two of its larger tributaries and also a cross-section of the ureter all surrounded by 
loose areolar connective tissue with no fascia or ligamentous tissue. 

Fig. 3 shows the section taken % cm. further lateral with the ureter, artery, and vein 
in cross-section. All are completely imbedded in loose areolar tissue. Near the 
artery is a vein partially closed witli calcareous deposit around which a layer of 
muscle and fibrous tissue which is a tangential section. There is no sign of any 
ligament. 

Fig. 4 shows a transverse section through the parametrium just above the vagina 
and lateral to the uterus. In the center is the ureter ; on one side is the vein and on the 
other side is tlio artery cut across twice because of tortuosity. At one side of the sec- 
tion is a wall of the broad ligament. There is considerable loose areolar connective 
tissue and fat tissue all around the vessels but no ligament or fascial structure. 



72 


AMERICAN JOURKAL OF OBSTCTRICS AKD OYXECOLOGY 


Fig. i3 is a section of tl\c iiroad ligainent taken parallel to tlic lateral wall of tlie 
uterus. It shows the vessels of the tube nt one end. the round ligament near the middle 
and the uterine ves.sels nt the other end, Avitli considerable fat tissue but no sign of 
fascial structure or ligament. 

Examination of cross sections of parametrium adjoining the junction of the uterine 
body and cervix through which coursed the uterine vessels taken from operative inn- 
terial obtained from eases where tot.al hysterectomy was performed corroborated the 
findings in the autopsy material. NoAVhere in the ti.ssue around the rrterine vessels 
as they approached or readied the uterus, was any ligamentous ti.ssue found. 



Fig. 4. — Further l.ateral wiUi ureter and vessels but no uteropelvic ligament. 



Fig. 5. — Section of broad ligrament parallel to the l.ateral nmll of the uterus 
showing the I'ound ligament and uterine vessels but no fascial structure or 
ligament. 


COJIMENT 

Ji'Iici'oseoiDically, there is no tvell formed, dense, fascial tissue in either 
the rectovaginal or vesicovaginal septum. The tissue separating tlie rectal 
from the vaginal, and the vesical from the vmginal walls is a loose, areolar 
connective tissue. The tissue, because of its character and composition, 
could have no restraining action in the prevention of either rectocele or 
cystocele and could also have no value in the repair of such conditions. 

Macroseopieally, in the adult, there is no tissue found in the neighbor- 
hood of the uterine artery extending from the uterus- at the junction of 



KOSTER: ON SUPPORTS OF UTERUS 


73 


tlie cervix in. tlie body outward toward the lateral wall of the pelvis, which 
is at all comparable to the ligamentous structure known as the cardinal 
ligament. 

Microscopically, in the adult, there is no such tissue demonstrable. That 
the round ligament could not be the only mechanism by means of which 
the uterus Avas kept in its normal position is certainl}^ generallj’" accepted 
by nOAv. Were there a similar ligamentous structure attached to the 
uterus at the junction of the body and cervix and to the lateral pelvic wall 
it would still remain to be shoAvn that it Avas the only or even an important 
factor in the maintenance of the noi'mal position of the uterus. According 
to our histologic studies hoAvever, no such tissue is aAmilable for the support 
of the uterus, either as a distinct ligament or distinct fascia. The only tis- 
sues found in that neighborhood were loose areolar conneetiAm tissue and 
fat. Thus, the prominence given to the uteropelvie or infundibulopehdc 
or jMackenrodt ligaments as supports of the uteims is umvarranted. Not 
only is there no such ligamentous tissue but the prominence giA^en to these 
ligaments as supporting structures to the uterus, is totally unAvarranted. 
It is interesting to note in this connection that in Piersol’s and Gray’s anat- 
omy, under the heading of uterine support, mention is made only of the 
round, broad, and uterosaeral ligaments. 

It also becomes manifest then that the operations for the cure of pro- 
lapse by plication or shortening of the cardinal or Mackenrodt ligament 
as advocated by Nyulasy° have no rational basis. 

Also in proposing a rational explanation for the development of pro- 
lapse, and its cure, these so-called ligaments must be excluded from 
consideration. 

CONCLUSION 

Tliere is no ligamentous tissue, Avhich might by its presence be able 
to support the uterus, to be found in the base of the broad ligament around 
or near the uterine vessels and extending from the uterus out to the lateral 
pelvic Avail as described in some texts under the name of Mackenrodt liga- 
ment, the cardinal ligament, the uteropehuc ligament or the infundibulo- 
pehdc ligament. The name ligament attached to any structure existing in 
the base of the broad ligament and surrounding or near the uterine vessels, 
extending from the cerA'ix out to the lateral pehde Avail is a misnomer and 
is distinctly misleading. The uterus cannot depend for support on any 
structure to be found in the base of the broad ligament, running from 
the cervix out to the lateral pehde Avail and prcAdonsly designated as the 
IMackenrodt, the cardinal, the uteropelvie or the infundibulopehdc liga- 
ment any more tlian it can on any and all the tissues to Avhich it is at- 
tached. The explanation of the deA’elopment of prolapse and its cure, can 
no longer include a consideration of these so-called ligaments. Opera- 
tions designed for the cure of prolapse of the uterus by shortening the so- 
called cardinal, IMackenrodt, nteropchde or infundibulopehde ligaments 
liaA'e no rational basis. 



74 


A3IERICAN JOURXiVL OF OBSTETRICS AND GYNECOLOGY 


REFERENCES 


(1) Bisucll, Doiujal: Surg. Gvjiec. Obst. 48; 549, 1929. (2) BMr, Bell: Prin- 

ciples of Gynecology, 1910. (3) Goff, Byron II.: Surg. Gynec. Obst. 52; 33, 1931. 
(4) MachcnrocU, A.: Arch. Gynec. 48: 393, 1893. (5) Xyulasy, Arthur J.: Surg. 
Gynec. Obst. S3: 53, 1921. (G) Spaitldinff: Am. J. Obst. & Gyxec. 12: G55, 192G. 

284 New Yokk Avekue. 


INTERNAL ROTATION OF THE FETAL HEAD FROM THE 
VIEWPOINT OF COMPARATIVE OBSTETRICS^ 

Lons RunoLiMi, M.S., il.D., F.A.C.S., and A. C. Ivy, PhD., M.D., 

CmcAGO, III. 

(From the Department of Physiology and Pharmacology, Northwestern 
University Medical School) 

'^HE scientific investigation of the mechanism of labor began ivith 
Oulcl in 1742^ when lie observed tliat the fetal liead entered the pelvic 
excavation with the sagittal suture in tlie transverse diameter. The pi’e- 
vailing tlieory at that time was that the fetal head entered and passed 
tliroiigli the pelvic excavation with the sagittal suture in the anteropos- 
terior diameter, appearing as if the child crept into the world. Saxtorph- 
and Solaryes® threw more light on this question by their observation that 
the fetal head entered the pelvic excavation with the sagittal suture in 
one of the oblique diameters, a view supported by Baudelocque'* and 
Naegele® and now generall)" accepted by the profession. Levret® in 1762 
emphasized the importance of the mechanical factor in labor thus giving 
rise to the so-called obstctrico-matheraatical school which was to influence 
later obstetric thought. Rigby" in 1841, realizing the mechanical trend 
of obstetric thought, wrote, “In the last century, it was so the fashion 
to resolve every physiologic process into a mathematical problem.” Our 
studies of the physiology of the uterus in labor®> ° have caused us to in- 
quire into the mechanism of the internal anterior rotation of the fetal 
head. These studies have led us to the conclusion that the uterus plays 
an important role in rotating the fetus, particularly in lower animals. 

A remew of the literature will demonstrate that internal rotation of 
the fetal head appears to be based, in the main, upon the mechanical fac- 
tors of the pelvis. On the contrary, a number of Avriters have presented 
evidence that the uterus, or even the fetus, is or may be a factor. No 
attempt will be made at this time to reAucAV the evidence pro and con and 
to discuss the various theories. HoAvever, having made such a rcAdew, 
we are of the opinion that the teaching of Denman^® and Rigby, which 
maintains that the adaptation to and propulsion of the fetus through the 
pelvic cavity is only a mechanical incident resulting from a physiologic 
process, has not been sufficiently appreciated. 


•Read at a meeting' of the Chicago Gynecological Society, Februai-y 19, 1932. 



RUDOLPH AND IVY: INTERNAL ROTATION OF FETAL HEAD 


75 


It occurred to us that a study of comparative obstetrics or the phylo- 
genetic history of pregnancy and parturition might throw some light on 
the subject. We shall briefly outline the evolution of the pelvis, the 
physiology of the uterus in labor in vertebrates, and record the observa- 
tions we have made on internal rotation of the fetus in the parturient 
dog, pointing out that due to moi-phologie changes in the pelvis, the uterus 
accommodates its function accordingly. 

THE PELVIS 

In the following brief review of the comparative anatomy of the 
pelvis,^' it will be noted that as the progenitors of man became more 
erect, the architecture of the pelvis changed to meet the requirements 
best suited to subserve the function required by the orthograde posture. 



Fig. 1. — Photograph of the lateral and posterior views of the pelvis of the chicken. 

In the fish, the primaiy requirement for existence is locomotion, so that Nature 
has provided tlie spinal column for that purpose. The caudal vertebrae are par- 
ticularly mobile and not hampered by a definite pelvic girdle to liinder the mechanism 
of propulsion. Here we find the first rudimentary indication of a pelvis consisting 
of two calcified or evenly ossified pelvic plates which become segmented from the basal 
cartilage and are held in place by cither a cartilaginous or a ligamentous attachment. 

In birds, we come to a group whose existence is dependent both on flight and on 
the ability to use the hind limbs for locomotion on land. The exception to the rule 
IS presented by the South African ostrich which has a well formed pelvis and depends 
on its hind limbs for locomotion in flight. The vertebral column is semirigid and 
the pelvis is designed to support the hind limbs. The pelvis is developed more dorsally 
than vcntrally. It is fixed posteriorly to the lateral part of the sacrum. Anteriorly 
the two halves of the pelvis are separated from each other, but are connected by 
either a cartilaginous or ligamentous attachment, which completes the pelvic girdle 
(Fig. 1). In fish and in birds, the pelvic aperture is large in comparison to the eggs 
tliat must pass through, so that in the expulsion they do not meet with much mechani- 
cal resistance. 





76 


A3IERICAX .JOURNAL OR OBSTCTRIC.S AND GYNECOLOGY 


The pelvis of the inamni.al is firmly attached to the vertebral column and there 
exists a union of the j)ubes and ischium anteriorly in the 7nidlinc to form a symphysis. 
By gradual stagc.s, the ischium spreads laterally from the ischiopubic symphysis, 
forming the pelvic arch, which is clearly demonstrated by a .study of the dry pelvis 
of the mammal (Fig. 2). 

A study of the pelvis of the monotremes, marsupials, rodents, ungulates, carnivores, 
and the monkey.s demon.strates tliat the -sympliy.si.s is rpiite Jong, and that the ischio- 
pubic arch varies. 

In the anthropoid apes and in man, we note a radical change from the lower mam- 
mals in that the ischiopubic symphysis changes. The symphysis becomes shorter and 
the ])ubic arch greater, reaching its greatest relative .shortne.ss and forming the great- 
est pelvic arch in man (Fig. 2). Ffchum.aim” points out that in the lower animals the 
ischiopubic symiihysis is ;ipproxininlcly one-half of the pelvic length. The infantile 
human pelvis is like that of a <piadru])ed pelvis in that its ajitcroposterior diameter is 
greater th.an the tr.'insverse and is quite similar to that of the highest apes. This 
change in the morphology and length of the symphysis is related to the evolution in 
the mode of the tnechanism of labor of all vertebratae in that the diameters of the 
pelvic inlet in relation to the fully developed fetus ))lay a rfde in determining the 
position of the presenting j)art for physiologic birth. For a complete review, the 
reader is referred to tschumann.” 



Fig. 2. — Diagnaninintic j-ein'csentations of (A) the primitive mammalian and (B) the 
human type of ventral .symphysis. (Taken from Jones, .-Irl/oi'cnJ Jfoii.) 

PARTURITION 

In fish, most of wliieh are oviparous, the ova are stored in an ovisac which is p.avt 
of the celomic cavity. Spawning is brought about by abdominal contractions and 
the unfertilized ova pass out through the abdominal pores. The slinrk-like fish 
(Elasmobranchii)”’ “ are ovoviviparous and oviparous. The eggs arc fertilized in 
the oviducts and develop in the uterine enlargements of the ducts. In the shark-like 
fish which are viviparous, we must assume that the fetus or fetuses at term are ex- 
pelled from the uterus by a meclianism of parturition consisting of a relaxation of 
the genital openings, and of abdominal and uterine contractions. 

In birds wbicli are oviparous, we find that the anatomy and the physiology of 
parturition are closely allied to the Iiigher mammals. Vender” in 1SS4 compared the 
normal parturition in the human being to the rotation of the egg within the oviduct 
of oviparous (birds) animals before its exit. The luiillerian ducts, one on each side 
of the vertebral column, form the oviducts. At maturity, the right oviduct and ovary 
atropliy. After the ripening of the yolk, it enters the ostium abdominalo tubae of the 
left oviduct, passing down through the oviduct in a spiral rotatory manner on its chala- 
zal axis due to peristaltic activity. The musculature of the oviduct is spirally ar- 
r.anged. During the descent of the egg, the albuminous layer is deposited in spiral 
coats. The shell membrane is laid on in the uterus. 



KUDOLPH AND IVY: INTERNAL, ROTATION OF PETAL HEAD 


77 


The egg passes down the oviduct with the pointed end first.*' Aristotle’* wrote 
that the blunt end of the egg is laid first. This has been confirmed.” *” ” Due to the 
work of Wickman,’* it appears to be settled that the egg passes down the oviduct with 
the pointed end first, but that in the expulsion of the egg from the shell-gland or 
uterus, it is turned usually 180 degrees on its short axis to be deposited externally 
with the blunt end first. That is, the egg undergoes a “version of ISO degrees” 
usually before or during the delivery of the egg. 

The mechanism of the delivery of the egg: From the uterus or shell-gland the egg is 
emptied into the cloaca by the relaxation of a strong sphincter at the lower pole of the 
uterus and peristalsis of the uterus. The expulsion of the egg from the cloaca is ae- 
.eomplished by a mechanism of eversion of the cloaca, or, the uterus still enveloping the 
egg is prolapsed through the cloaca and the vagina and the egg is laid without having 
touched the walls of either the cloaca or the vagina.” 

The pelvis is very probably a mechanical hindrance to the physiologic function of the 
uterus and is not essential for parturition in certain lo'U'er forms. This is indicated by 
a study of the shark-like fish (Elasmobranchii), the whale (cetacea),” *“*’ and the seal, 
se.a lion and walrus (aquatic carnivora) which have onlj’ a rudimentary pelvis and are 
viviparous. In the shark-like fish, labor must be dependent upon the uterine and abdom- 
inal contractions. In the whale and in the seal, sea lion and walrus, the uterus is bi- 
cornate, so the mechanism of labor should be the same theoretically as occurs in those 
terrestrial animals which have a uterus bicornis. Since they have onlj' a rudimentary 
pelvis, the pelvis is not essential for parturition in these animals which possess a uterus 
intermediate in differentiation. 

In the moiiotreines, the two miUlerian ducts become the two uteri. Each opens into 
the urogenital sinus on its respective side. These animals are egg-laying mammals, and 
we may assume that the mechanism of egg-laying is similar to the birds. How they are 
propelled through the urogenital sinus and the cloaca, we have been unable to determine. 

In the marsupials, the two miilleriau ducts become the two uteri which fuse just be- 
fore reaching the urogenital sinus. The fused portion becomes the vagina, which opens 
almost immediately into the cloaca. These animals are egg-laying mammals and we 
assume that the fertilized ovum is propelled downwards through the uterus and through 
the cloaca to the vulva in the same manner as in the bird. Parturition takes place with 
the fetus in a premature state in the egg, which is arrested at the vulva, where the shell 
membrane ruptures. The fetus reaches the marsupia by its omi locomotion and becomes 
fixed to a teat of the mammary gland.** 

From the rodents to man, we reach a stage in the evolution of the uterus and parturi- 
tion on the basis of which we may correlate homology and physiology. 

In the uterus didelphys, uterus bicornis and the uterus simplex, we find certain out- 
standing structural and functional analogies as follows: The upper uterine segment 
which has the property of isometric contraction and retraction, manifests powerful 
peristaltoid contractions. The lower uterine segment with its property of relaxing, 
stretching or thinning manifests “loss powerful” peristaltoid contractions. In addi- 
tion, we find the presence of the “Ring of Bandl” (fundal sphincters) between the 
upper (cornua) and the lower (corpus uteri) uterine segments, and its correlated physi- 
ologic properties; the cervix uteri with its cervic.al canal, os internum and os externum 
and the similarity of its functions, being plugged during the pregnant state by mucus; 
and that during the second stage of labor, the uterus is assisted in the e.vpulsion of the 
contained ovoid by the auxiliary forces. 

In the rodents, the uteri arc perfectly formed, each with a well-formed cervLv, sep- 
ar.ated from each other, but opening into a single vagina (uterus didelphys). During 
labor, one of the lowermost ampullae of one uterus becomes active, divides into an upper 
and a lower uterine segment, and nianife.sts a mochani.sm of labor that is similar to other 
mammals. The fetuses are expelled nornmlly in a dorsosacral position. The lower 



78 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


uterine segniciit is derived from the loworniost. ampulla of eaeli uterus and is the com- 
mon lower uterine segment for the expulsion of each successive fetus from each respec- 
tive uterus.*® The upper uterine segment is derived from the upper part of the lower- 
most ampulla by retraction and a sustained longitudinal contr.action. After the expul- 
sion of the first fetus that part of the upper uterine segment merges with the ampullae 
above by retraction, and becomes in part the upper uterine segment for the mechanism 
of expulsion of each successive fetus from that uterus. This merging of tlie ampullae 
goes on until .all of the fetuses are expelled. This physiologj* of the uterus of the rodent 
(rabbit) in labor u-ill bo published in more detail in a future publication. 

In the carnivores, we have the formation of the uterus bicornis unicollis. The two 
miillerian ducts fuse into a single tube at the lower or caudal extremities to become the 
corpus uteri or the lower uterine segment, with one cervix opening into a single vagina; 
the upper or the cephalic extremities remain separated to form the cornua or horns, 
which are quite long. We have studied the physiology of labor in the dog,* and we will 
briefly review the first and second stages of labor. The first stage is the expulsion of 
the lowermost fetus from one of the lowermost ampullae. Tlie corresponding fundal 
sphincter (Ring of Bandl) relaxes, and by refraction of the musculature of that am- 
pulla the fetus is expelled into the corpus uteri. The second stage begins ^vith a fetus 
in the corpus uteri when the relaxed fundal sphincter contracts, while the other sphinc- 
ter holds it tone; and contractions of the corpus uteri aided by the auxiliary forces 
bring .about the expulsion of the fetus. The mechanism of the cervix is probably the 
same as in the human being, but whether the dilatation occurs during the expulsion of 
the fetus from the cornu or after the fetus has entered the corpus uteri is as yet not 
known. 

In the ungulates, the same anatomical arrangement is found as in the carnivores, ex- 
cept that the cornua or horns arc relatively much shorter and the cervix is much more 
developed. During pregnancy, the fetus or fetu.scs arc developed in the cornu, or cornua 
in the case of twins, and the corpus uteri. We have studied the physiology of the uterus 
in the sheep in labor, and in pregnant uteri of the cow in various stages during preg- 
nancy. With the onset of labor, the pregnant cornu with each uterine contraction 
shortens by its property of retraction and pulls upward on the fundal sphincter. The 
continued shortening of the cornu or the upper uterine segment has the effect on the 
corpus uteri or the lower uterine segment of stretching or thinning it. This we believe 
brings about some cervical effacement and dilatation, which is further amplified by the 
presenting portion of the fetus in the corpus uteri. With the dilatation completed, the 
contraction of the cornu brings about expulsion of the fetus aided bj' the auxiliary 
forces. 

In the primates, we find a complete fusion of the upper and the lower portions of the 
mullerian ducts forming a uterus simplex or arcuatus with a cervix which opens into a 
single vagina. Ivy, Hartman and Koff*® h.ave studied the physiology of tlie uterus in 
labor in the macacus rhesus and have pointed out certain homologies and .analogies be- 
tween the uterus of the monkey, dog, and man. It is known and can be demonstrated 
that the fetal head enters the pelvic ca^-ity with the head in complete extension, the fetus 
being delivered in a position similar to the rodent, dog and mare, that is, in .a dorso- 
saeral position. A study of the monkey’s pelvis demonstrates its similaritj- to tliat of 
the carnivores and ungulates, except that the promontory of the sacrum is more marked 
in the monkey. A study of tlie fetal skull and maternal pelvis in the monkej’ shows that 
the head must pass through the pelvic cavity in extension in a dorsosacral position. Dur- 
ing pregnancy, Hartman*’ has found that the back of the monkey fetus is to the right 
or left side of the mother’s abdomen. 

In the anthropoid apes, the literature of the mechanism of labor is very meager. 
Fox** has described labor in a chimpanzee with the head delivering as an occipitoposte- 
rior. After the delivery, the face rotated to the left. Tinklepaugh*® described a portion 



KUDOLPH AND IVY: INTERNAL ROTATION OF FETAL HEAD 


79 


of parturition in a cMmpanzec (during labor the cbimpanzee became frightened and 
jumped onto a screen partition, and in the jump the fetus was expelled) . Eive days be- 
fore the delivery, the position of the fetus was O.L.A, Just before the animal jumped, 
the head appeared at the vulva rvith the sagittal suture in the anteroposterior diameter, 
and the occiput posterior. From a comparative study of the dry pelvis and the shull 
of the anthropoid apes, it would appear that the fetal head should be delivered as in the 
human being, through the pelvic cavity by internal anterior rotation, because the trans- 
verse diameter is greater than the anteroposterior diameter of the pelvic inlet. 

INTERNAL ROTATION 

Tiie position of the fetns in ntero during pregnancy and labor in the 
ungulates will be presented in order to emphasize the type of internal rota- 
tion that occurs. We will study the mare (Rumiuantia) 

During pregnancy, the fetns or foal lies usually in one of the cornua and the corpus 
uteri on its hack on the floor of the mare ’s abdomen mth the head towards the pelvic in- 
let and the hind end in the upper end of the gravid horn. The. fetal chin is on the chest, 
the fore legs bent at the knee, and the hind legs flexed. This is the dorsopubic position 
(Fig. 3) . The foal may lie on its side or in the dorsoUiac position (Fig. 4). "Williams"' 
has recently found that the.dorsopubie position is not the only prenatal position of the 
foal, since he and his associates have found by rectal palpation that the foal may lie 
either in a dorsoiliae or a dorsosacral position. A roentgen study has not been made. 
The presentation is anterior or cephalic in from 95 to 96 per cent.“ 

A. study of the pelvis and the fetal head of the mare, cow, and sheep demonstrates 
that the physiologic relations between the diameters of the pelvis and the presenting 
part of the fetus are such that in the mechanism of labor the fetus must rotate fre- 
quently from 90 to 180 degrees, or from the dorsoiliae or the dorsopubic position, in 
order to reach the normal presentation and position of a cephalic dorsosacral position 
for physiologic birth (Fig. 5). In a hind end or breech presentation and position, 
the foal must bo with the back to the maternal back uath the hind legs fully extended 
whicii is a posterior or breech dorsosacral position. This rotation occurs preparatory 
to birth or during the first stage of labor. The presentation undergoes changes in 
which the fore legs and head are extended ; the vertex is in relation to the hollow of 
the sacrum, and the chin and the anterior portion of the neck are in relation to the 
ischiopnbic sjTnphysis. As the head is being delivered, restitution begins to occur, 
which is flexion of the head or a return to the position in which the head was prior to 
labor. It is to be noted that when effacement and dilatation of the cervix are com- 
pleted, and the foal is in position for delivery, it must ascend about 45 degrees in or- 
der to pass over the ischiopubic symphysis and through the pelvic inlet. 

IFo may add, at this time, that the component parts of the mare’s uterus may be 
compared to tho human uterus at this stage. Tljo pregnant cornu is analogous to the 
upper uterine segment. The corpus uteri and tlie cervi.v are analogous to the lower 
uterine segment and the cervix. At the junction of the cornua and the corpus uteri is 
found a definite sphincter-like structure which we call the fundal sphincter, similarly 
to the structure found in the dog,’ which is analogous, we believe, to the “King of 
Band!. ’ ’ During labor, tlie nonpregnant cornu, Avhich has also undergone hypertrophy, 
is kept closed by an isometric contraction of its corresponding fundal sphincter which 
prevents the foal from entering the nonpregnant cornu. The veterinarian literature 
states that the nongravid horn is kept closed and prevents the foal from entering on 
account of a synchronous contraction with the active gravid eornu; (we believe that 
tho nongravid horn is to be considered more or less passive during parturition). 

With tho foal in a normal ])resontation .and position, the e.vpulsion of the animal is 
brought .about by the uterine activity of three types: (a) contraction, (b) “isometric 





RUDOLPH AND IVY; INTERNAL ROTATION OF FETAL FIEAD 


81 


stretcliecl bring about effacement and dilatation of the cervix along Avith relaxation, of 
the smooth muscle forming the cervical sphincter. 

A consideration of the anatomy of the pelvis and the uterus in the mare, and the 
changes of the foal on its longitudinal axis excites the query, what causes the rotation 
of the foal? Smith‘d' and de Bruin“ state that the uterine contractions cause the foal 
to be rotated on its longitudinal axis; and that the extension of the fore legs is due to 



Fig. C. — A. — A roentgenogram of a clog in labor. The head is entering the corpus uteri in 
a cephalic dorsopubic position. The body is approximately in a dorsoiliac position. 



. ’■ocntgenogram of the same dog as in Fig r.-A with iho Uoo.i „ i , 

rotated to a dorsosacral po.sition, tlie head bein"- at tho nutiot ci^Vio * . bead and body 
before Uie head passe.s the inlet " ' Similar rotation may occur 




82 


AMEinCAN JOUIJXAL OF OBSTETRICS AND GYNECOLOGY 


the result of the fetal movements. The gravid horn is so placed that the angle between 
the a.xis of the gravid horn and pelvic axis is about 45 degrees. The resistance that the 
presenting part meets occurs only during the duration of the uterine contractions. In 
the interval between tlio uterine contractions, we can readily see that by gravity and 
relaxation of the uterus the foal would tend to lose its contact with the bony pelvic 
inlet. Recalling the above outlined changes of the position of the foal, we note that 
the inclined planes, the ischial spines, and the pelvic floor of the mare take no part in 
aiding or bringing about internal rotation of the foal on its longitudinal axis. Since 
the pelvic inlet cannot account for the rotation, and since we cannot believe that the 
fetus crawls into position, wo must .accept the premise that the uterine contractions are 
responsible for the rotation of the foal into a normal presentation and position for the 
physiologic birth. 

Because of the similaritj* of the pelvis and the uterus between the un- 
gulates and the carnivores, we undertook a roentgenograpliie study in 
the dog to determine the position of the fetuses during pregnanej^ and 
parturition. 

Roentgenograms of pregnant dogs from thirty dn 3 ’s to near term were made. On 
the onset of labor or after one or more pups had been delivered, roentgenograms were 
taken at intervals, or in scries. By direct observation, we have also determined under 
anesthesia with the abdomen open, the presentation and position in which the pups 
were delivered. A majority of the deliveries were studied by vaginal examinations 
during the passage of the pups through the pelvic cavity, the findings being correlated 
with the x-ray plates. No anesthesia was required. All dogs cooperated remarkably 
well. The roentgenograms were taken in three positions: lateral with the dog Ij’ing 
on the plate ; lateral with the dog standing on all fours with the plate held in position 
by a specially constructed, adjustable plate holder; on its back with the fore and 
hind legs held apart on a plate. We found that the most practical position was mth 
the dog Ij’ing on its side. Roentgenograms show that this position does not cause a 
material change in the position of the fetuses. Fourteen dogs were studied during 
pregnancy and labor. 

During pregnancj', the roentgenograms showed that the majority of the pups in the 
horns are in a dorsopubic position, with some in a dorsosacral position, and others in a 
transverse position. The transverse position is due to the marked enlargement of the 
horns which become somewhat fle.xcd on themselves, so that an “apparent” transverse 
position is found on the roentgenogram. 

Note : For lack of space the protocols of the experiments made in dogs cannot be 
included. 

Our evidence shows that the presenting fetus not only rotates during 
its passage through the eoi'pus utei'i, but may rotate (but not always) to 
a dorsosacral position before it entei’S the pelvic inlet. Every one of the 
ninety pups whose birth was observed was delivered in a dorsosaci’al posi- 
tion. If the fetus enters the corpus uteri in an approximate dorsosacral 
position, very little rotation may result. ‘‘Superrotation” oeeiu’red in 
one instance. The fetus maj’’ enter the pelvic inlet in a dorsoiliac or dor- 
sopubic position, but in such instances, rotation to a dorsosacral position 
occurred before birth. 

The rotation to a dorsosacral position is practically complete as a rule 
before the fetus strikes the pelvic floor. The head is fully extended dur- 
ing passage through the corpus uteri. We could not decide from our 


RUDOLPH AND IVT : INTERNAL ROTATION OF FETAL HEAD 


83 


roeiitgBiiogi'aDis tliG direction of tlie rotation, or wlietlier tlie dii’ection 
depended on the horn from n’hich the fetus passed. This is an important 
point because the direction of rotation may depend on the horn from 
which the fetus comes and which is turn may have some hearing on the 
direction of rotation of the fetal body in the human being. 

The long labors were apparently due to abnormal positions caused by 
uterine dysfunction. It is interesting that one fetus may he delivered 
slowly and apparently Avith difficulty, and then the folloAving fetus be 
delivered AAuthin a feu^ minutes. This indicates that the disturbed func- 
tion was temporary. The observed fact is that in the dog the fetus ro- 
tates during passage through the corpus uteri. 

SUMMARIZING STUDY OF COMPARATIVE OBSTETRICS 

A revieAA' of our IcnoAvledge of comparative obstetrics emphasizes the 
exceedingly interesting evolution of the morphology of the pehus and the 
uterus and thrOAVS light on the physiology of the uterus. The gradual 
change of the pelvis from the fish to the human being demonstrates the 
relation of structure to functional activity. The change in the postural 
attitude from the pronograde to the orthograde Avas associated Avith a 
logical mechanical change in the architecture of tlie pelvic girdle. 

The oviduct of the bird propels the yolk doAvnAvard in a spiral manner 
to the shell gland or uterus, and “version” of the egg of 180 degrees on 
its short axis occurs^® usually in its delivery. In the mare, the foal is 
rotated frequently from 90 to 180 degrees for physiologic birth in a dorso- 
sacral position or in the largest pelvic diameter. We liave found in the 
dog that the fetus is rotated in some instances from 90 to 180 degrees for 
physiologic birth. This amount of rotation may or may not occur 
(usually does not) before the fetus enters the pelvic inlet, the amount of 
rotation varying Avith the position in Avhich the fetus enters the corpus 
uteri. Most of the rotation occurs in the corpus uteri or just before the 
fetus enters the vagina. In tliis connection it is interesting that rupture 
of the uterus has been observed^® in the dog due to impaction of the fore- 
part of the fetus in the pcMc cavity in a dorsopubic position, Avhich is 
analogous to impaction in the mentoposterior position in the human 
being. Hartman’s®" study of parturition in the monkey (Macaeus rhe- 
sus) has demonstrated that the fetus is delh^ered in a dorsosacral position 
witli the head fully extended. It Avas found''" by palpation that the back 
of the monkey fetus is found usually to the right or left side of the moth- 
er’s abdomen. Our study of the monkey’s pelvis has shoAvn its similarity 
to the pelvis of the dog and mare in regard to the peh'ic inlet and caAuty, 
except that in the monkey, the promontory of the sacrum is more marked. 
And a study of the fetal skull and maternal pelvis shoAvs that the only 
manner in Avhieh the licad could pass through the pelvic caAuty Avithout 
meeting considerable ohstrucHon or CA^en impaction resulting, is in exten- 
sion in a dorsosacral position, the body folloAving through. On the basis 



84 


AMI^RICAN .JOUnXAb 01^ OBSTETRICS AND GYNECOLOGY 


of our studies, we must conclude that in lower animals the uterus is prima- 
rily responsible for placing the fetus in a dorsosacral position with head 
extended, the position in which is found the greatest pelvic diameter, 
for physiologic birth. The truth of this generalization was recognized 
by Schumann, who in speaking of rotation points out that it consists “not 
in rotation of the presenting part upon the pelvic door, nor do the pelvic 
walls play an important role in this phenomenon,” it being more of an 
accommodation of the greatest diameter of the fetus to the greater axis 
of the maternal pelvis. 


CHIEF DIFFERENCE BETWEEN LOWER FORMS AND 
THE HUMAN BEING 

In the apes, monkeys, and quadrupeds, tlie largest pelvic diameter 
throughout is anteroposterior, whereas in the adult human being at the 
inlet the largest diameter is transverse, the promontory of the sacrum 
being more marked. In these lower forms, the fetal head is delivered in 
extension, occipitoposterior (not definitely settled in apes), 'in the human 
being, occipitoanterior. In these animals and in the human being, the 
head is born in the anteropostei'ior, or largest diameter of the outlet, but 
with opposite positions of the occiput. In other words, the change in the 
diameter of the pelvic inlet has been associated with a change in the posi- 
tion of delivery of the occiput. This is a fundamental difference, since 
even in most occipitoposterior positions in the human being, anterior rota- 
tion occurs. 

Another outstanding difference is in the position of the head during 
passage through the pelvis. In these lower forms, the head is in exten- 
sion throughout, flexion oecux'ing only after the chin has passed the 
ischiopubic symphysis. In the dog the head is extended during passage 
through the corpus uteri. In the human being, the opposite occurs; the 
head enters the pelvis slightly flexed, then flexion becomes very marked, 
deflexion occurring as the occiput passes the symphysis. The mechanism 
of delivery of a human fetus in a mentoanterior position is quite analogous 
to that of the dog. 

Further difference is found in the curvature of the birth canal. In 
these lower forms, although the birth canal is curved anteriorly, it is less 
so than in the human being. 

We maintain, on the basis of our obseiwations, that there is no difference 
in regard to the suugness with which the fetus fits into the birth canal. 
However, a difference does exist in regard to the amount of obstruction 
met with at the level of the pelvic floor. In lower animals the fetus is 
usually rotated into the position of least resistance before it strikes the 
pelvic floor; whereas, in the human being this is not entirely true, since 
the pehue floor does play some role in rotation. 

Since the uterus of lower animals is apparently the chief factor which 
accommodates the fetus to the pelvic cavity for phj’siologic birtli, the 



KUDOLPH AND IVY: INTERNAL, ROTATION OF I^ETAL HEAD 


85 


questions arise, lias tlie human uterus retained tliis phylogenetic property 
of rotating and adapting the fetal ovoid in relation to the morphologically 
changed pelvis, or as the morphology of the pelvis changed, did the fun- 
damental physiology of the uterus change? 

COMMENT 

In the Human Being . — It is known that all hollow viscera have a normal 
shape and posture which are maintained primarily by the anatomical 
arrangement and tone of the muscle fibers. Changes in tone of the muscle 
fibers lead to changes in postural tone (length and tension of muscle 
fiber) of the organ, or the outline, contour and position of the contents 
of the viscus. Gravity affects the posture of a muscular viseus, particu- 
larly if the abdominal musculature is atonic ; but obviously this means 
that the tone of the muscle of the viscus is insufficient to overcome the in- 
fluence of gravity (ligamentous supports remaining constant). These 
facts are pointed out to indicate that the postural tone of the uterus is 
an important factor in determining the position of the fetus during the 
latter part of pregnancy and more particularly during labor except in 
cases of polyhydramnion. In eases of polyhydramnion that come to 
term, and in multiparae with a flaccid uterus and lax abdominal walls, 
it is known that malpresentations frequently occur.'^® In a previous 
article® we have presented evidence indicating that the uterus possesses 
a coordinating mechanism, which makes possible a purposeful and har- 
monious movement, a disturbance of which causes variations in muscular 
tone in different portions and may lead to abnormal positions, presenta- 
tions, or prolonged labor. IVe maintain, therefore, that the postural 
tone of the uterine musculatni’e -which is, of course, markedly increased 
during contractions, is the basic factor concerned in determining the 
presentation and position. This is somewhat analogous to the view of 
Olshausen,®® Schmitt,®® which was accepted by Bumm®^ and others®- ®® 
which holds that in labor, “the uterus tends to assume its oi’iginal flat- 
tened form,” and is analogus to the “theory of accommodation,” which 
with gravity, is used to explain the frequency of cephalic presentation. 

Our contention is that as the transverse diameter of the human pelvis 
became the larger diameter, the uterus adapted its physiology to meet 
this change in morphology. It is difficult for us to believe that the fact 
that the sagittal suture enters most commonly either the oblique or trans- 
verse diameter of the pelvic inlet in man is a “mechanical accident,” or 
that “Nature,” in such an important process as birth, would rely solely 
on the possibility that force applied to the fetal ovoid ivould eaiise it to 
seek the larger opening, or that the “directing force” manife.sted by the 
uterus in lower animals has been lo.st entirely by the human nteru.s. How- 
ever. we do not intend to imply that mechanical factors do not play a 
role in the causation of flexion, deflexion, and rotation.® 

m-ovinco of this p.-iper to consider ceplialoiielvic di.spropor- 



86 


AJIERICAX JOURNAL OP OBSTETRICS AND GYNECOLOGY 


In the dog, we have observed abnormal positions at the inlet. Althoiigli 
associated with prolonged labor, the abnormal position may be corrected 
in time by the uterus, or befoi-e the head has passed through tlie cervix, 
or much beyond the inlet, jbialogonsly in the human being it is not 
uncommon to find the head in an abnormal presentation at term (x-ray), 
i. e., a brow, a mento or an intermediate presentation, and in the majority 
of cases the nialpresentation is corrected spontaneously. Also in most 
eases of “ deflexion attitude,” spontaneous correction occurs. The ques- 
tion arises, is the uterus, or the mechanics of tlie pelvis, primarily con- 
cerned in the production and correction of such conditions? 

In a previous paper we have expressed our conclusions in regard to 
malpresentations.® 

In regard to deflexion attitudes, obstetric experience teaches that such 
a condition is associated with a dystocia syndrome characterized by pro- 
longed labor, slow effacement and dilatation, lack of descent of the head, 
arrest, or slow rotation of the fetal head, and so-called inertia uteri. (We 
believe that inertia uteri is a condition in which the longitudinal and 
oblique muscles fibers of the upper segment do not manifest their im- 
portant property in labor of i.sometrie eontraction, or su.stained longi- 
tudinal shortening, which leads to retraction and “capping” and holds 
or fixes the progress or advantage gained by the preceding contractions.) 
The attitude of the head in the dog in labor is controlled by the same 
factors that operate in the human being, namely, a harmoniously con- 
tracting uterus throughout, the resistance to egress, and the classical 
unequally balanced two-armed lever than exists between the vertebral 
column (the support) and the head (a long and a short arm) (see Wil- 
liams®®). In order to get flexion of the head in the canine fetus, the snout 
would have to be lodged in a “paralyzed” pocket in the corpus utei-i or 
caught in a pocket proximal to a bon}’ protuberance. In cases of normal 
cephalopelvic relations in the human being, the utei’us mu.st be viewed as 
the primary cause of flexion because the force of the uterus, conti’aeting 
uniformly in its various portions, is transmitted to the fetal spinal col- 
umn. If the force transmitted through the fetal spinal column is mis- 
directed by improper coordination of the upper uterine segment, or if 
the lower segment or cervix is more atonic or yielding in one portion 
than another, the lever action will be modified or abnormal. This may 
or may not be corrected by a resumption of normal uterine activity with- 
out which even the normally distributed resistances in the pelvic canal 
Avould be of no avail. This property of the uterus has been referred to 
by Solaryes®® as the “I’efleeted force” and by Winchcll®® as the “guiding 
line.” Of course it is to be recognized that structural abnoi'malities in 
the pelvis, tumors, etc., may be the primai’y eause of deflexion. 

That internal rotation is not a simple phenomenon is shown, first, by 
the large number of explanations that liaA^e been offered, and second, by 



RUDOLPH AND IVY: INTERNAL ROTATION OF FETAL HEAD 


87 


the fact that the head may be rotated- either right or left depending on 
the position, and that during delivery the head may be rotated in one 
direction and then later the shoulders in the opposite direction. Most 
of the explanations offered are based entirely on mechanics. Only a few 
maintain that the uterus plays a primary role. Such a difference in opin- 
ion generally indicates that no single factor is concerned, as Cragin^'’ has 
pointed out. 

Schmitt,®® Olshausen,®® Schroeder’^ and Bumm®^ (also Spiegelberg,’’^ 
Barnes,^® Cazeaux,^-^ Gerdy,''® and others accepted the view in part) have 
contended that the uterus is the initial factor in rotation of the head 
because the uterus rotates the trunk anteriorly, the rotation being com- 
pleted by the gutter-like structure of the pelvic floor. More recently 
"Warnekros"® after a roentgenographic study of the fetus in labor, reports 
that the rotation of the body frequently preceded that of the head, but 
believes the pelvic floor plays the predominant part. That the trunk ma}" 
exert a rotating effect on the head is shown by the phenomenon of exter- 
nal restitution and by the fact that in a breech delivery, the anterior or 
posterior rotation of the after-coming head is influenced chiefly by the 
position of the bodj'’ (Cragin). The most obvious objection to this view 
is that it does not explain the rotation of the shoulders that occurs after 
delivery of the head. In regard to the pelvic floor, we agree with Para- 
more^^ in that the chief action of the pelvic floor is to project the advanc- 
ing fetal pole forward in a sagittal plane towards the pelvic arch. This 
is not rotation. We agree ivith Bdgar^® in that the advancing fetal pole 
will tend to move toward the area of least resistance, namely, the vulval 
slit. On the basis of these views we can conceive and grant that the pelvic 
floor may rotate the flexed head from a right or left occipitoanterior posi- 
tion (O.L.A. or O.D.A.) or even a transverse position, to an occipito- 
anterior (O.L.A.) in the second stage of labor. If this is accepted, there 
is no difficulty in Olshausen’s explanation. But ive cannot understand 
how the pelvic floor, the incline planes, ischial spines, Sellheim’s theory,’® 
etc., per se, may operate in causing anterior rotation of the occiput in 
posterior positions with full flexion. We believe, therefore, that the rota- 
tion of the trunk by the uterus plays an important role in rotating ante- 
riorly the occiput in posterior positions and in preventing posterior rota- 
tion of the occiput (O.P.) 

In this connection, however, the classical experiments of DuBois®® and 
Edgar’® cannot he disregarded. In their experiments, performed on a 
dead fetus and mother, the fetus (head flexed) was placed in a posterior 
position and either pushed or pulled through the pelvis. Anterior rota- 
tion occurred. This shows unquestionably that the resistance offered by 
the pelvic walls and floor plaj's a role in the causation of internal anterior 
rotation. But obviously the force had to be applied to tlie fetus in a 
'‘well directed manner” with the head flexed,®®’’^ since it wonld cer- 



88 


AJIEinCAX JOURKAL OF OBS’l’ETRICS AXD GYXECOLOGY 


taiiily be impossible to express or extract the fetus if the “clireeting 
force” were not properly applied to Ibe bead. This directing force in 
life comes from a harmoniously contracting uterus. 

Wo realize that Scllbeim’s view is more generally accepted. Sellbeini’s 
view teaches that a cylindrical body, which can be bent to different degrees 
in different directions, when forced through a curved cylindrical canal 
must rotate so that the ])ortio)i which bonds most easily will become accom- 
modated to the cnrvature of the canal. Since his data on recently deliv- 
ei'ed babies showed that the head is more readily extended than flexed, 
he argues that the markedly flexed had tends to extend and and that 
this tendency will cause the nape of the neck to rotate to the anterior 
curvature of the birth canal which at the same time causes extension. 
We cannot accept this explanation for three reasons: first, a dead, \m- 
macerated fetus is rotated in the natural birth process and DuBois and 
Edgar obtained rotation Avith a dead fetus experimentally; second, it 
implies that the lover action of the .spinal column on the fetal head 
operates to cause flexion but not extension of the head, Avhieh may be 
viewed as inconsistent ; and third, it holds that rotation is independent 
of the kind of or directional application of the force applied by the uterus. 

The mechanical principles by which the resistance of the pelvic floor 
and wails operate to facilitate anterior I’otation is best explained by Para- 
more, Ave believe. Paramorc’s explanation involves an appreciation of 
the mechanical principles of the tAvo-armed lever that is concerned in caus- 
ing flexion and extension. The only difl’erenee is that in fle.xion and ex- 
tension the resisting foi-ce is being applied perpendicularly to a “hori- 
zontal” plane and that in rotation the resisting force is being applied 
perpendicularly to a “vertical” plane. (Of course the planes are not 
perfectly horizontal or A’erfieal.) With the head Avell flexed, the fore- 
head is eccenti'ie in that the distance from the fetal axis to the sinciput in 
the “A’crtieal ” plane is greater than the distance from the fetal axis to the 
occiput. As the vertex strikes the pelvic floor, it is deflected antei'iorly 
The resistance offered to anterior deflection Avill be more effective on the 
forehead because the lever arm is longer. Hence, the forehead Avill move 
baelvAvard aboiit the fetal axis in a screAvlike rotatory manner. The 
levatores ani, decreased resistance of Auilval slit and the larger antero- 
posterior diameter of the outlet Avill assist after the vertex reaches an an- 
terior position (O.L.A. or O.D.A.). Flexion is essential, since it de- 
termines the length of the lever arms or the eccentricity of the forehead. 
Paramore recognized that an adequate driA'ing force from above AA’as es- 
sential to bring the forces into play. Young’s®® explanation is quite sim- 
ilar to that of Paramore except that the former holds that the ciuwature 
of the birth canal is important, a point that must be considered in aucav 
of the difference in the degree of eurAmture of the birth canal in loAver 
forms and the human being. We should add that this driA'ing force must 



RUDOLPH AND IVY; INTERNAL ROTATION OF FETAL HEAD 


89 


be properly directed by a uterine musculature u-orking harmoniously 
through a coordinating- mechanism. 

On learning that the oviduct of the ehiclien rotates the egg and in- 
version of the egg freciuentl3'^ occurs in lajung, that the small intestine im- 
parts a spiral movement to a bolus, that the vagina of the rabbit manifests 
a tortuous spiral-like activity, that the uterus of the mare and dog usually 
rotates the fetus to a dorsosacral position for physiologic birth, it occurred 
to us that one horn may tend to rotate the fetus in one direction, and the 
other horn in the opposite direction. Unfortunately our x-ray plates 
gave us no information on this possibility which awaits further study. 
Obviously if this actually occurs in the bieornuate uterus, it is possible 
that such a phenomenon maj’- have been retained in part bj^ the primate 
uterus. If so, it has an important bearing on the cause of internal 
rotation. 

Hence, we have searched the obstetric literature, and one of us (L. E.) 
has gone over his obstetric records to ascertain whetlier the human uterus 
ever manifests the property of “spiral action” Avhieh harmonizes with 
the longitudinal and circular forces to rotate the bodj" and head. Since 
the rotation of the trunk by the uterus was discussed above, Ave shall not 
discuss that subject again, but Ave should like to point out that this factor 
must be kept in mind in regard to the interpretation of the points Ave 
are about to discuss. 

Although internal anterior rotation generally occurs in the second 
stage of labor Avhen the presenting part is fullj’^ Avithin the confines of 
the pelvis, there are instances in AA'hich rotation occurs in the first stage 
and before the presenting part is under the full influence of pelvic fac- 
tors. Stephenson®® has stated that rotation maj^ occur in the os uteri or 
on the pelvic floor, so that one cannot confine rotation to an3^ limited 
portion. The fact, pointed out b3’' Gillespie®- and others®®- ®® that during 
uterine systole the presenting part rotates on its longitudinal axis and 
again recedes during uterine diastole frequentl3’- indicates that the re- 
sistances are not alAA-a3-s fixed. (We have noted the same in the dog.) 
In footling presentation, Schmitt®® argues that since the foot rotates while 
still in the pelvis, this rotation must be due to the rotation of the trunk by 
the uterus, a mechanism that has been suggested by Duncan®^ and Nagel.®® 
Further, in conduplicatio corpora, the mechanism of the spontaneous de- 
livery of the fetus is described by Douglas®® as being due to uterine contrac- 
tions, the fetus rotates about its vertical axis. One of us (L. E.) has ob- 
served that in occipitoposterior positions Avith the head engaged and Avith 
partial cervical dilatation, the head may rotate from a posterior position to 
the transverse and into an anterior position before complete dilatation of 
the cervix. This indicates that rotation may occur above the pelvic floor. 
This has also been observed by ZAA-cifel,®® Stephenson,®® Cazeaux,'-* and 
Edgar."® Since rotation apparently occurs at the higher IcA-els of the pelvic 



90 


iUtERICAX JOURNAL OF OBS-PETRICS AND GYNECOLOGY 


ca^dty, clurinpc livst stage, it is tinlikely that nicelianical factors in the 
pelvis are conccrnecl primarily. 

The following points emphasize the rotation of the trunk by the nterus. 
In a roomy pelvis, siiperrotation of the occiput or shoulders not infre- 
quently occurs (DcLec) . It is difficult for us to believe that such a turbinal 
movement is due to the mcclianieal factors in the ))clvis. Further, it is well 
known that if in persistent occipitoposterior positions in the second stage 
of labor, the head is rotated anteriorly manually or by a Seanzoni maneu- 
ver. the head will rotate back to its original position unless the back is ro- 
tated anteriorly or the head is held in place by the hand, a blade of the 
forceps, or with a Vulsella forccjis on the scalp (DeLce). This difSeulty is 
apparently due to the failure of the back to rotate anteriorly. Also one of 
us (L. E.) ob.scrved several years ago that in a diagnosis of O.L.P. or 
O.D.P., the back would occasionally be delivered in the opposite oblique. 
At that time this was ascribed to an error in diagnosis. In recent years, the 
diagnosis has been verified by I’oentgenograms made before delivery with 
the result that in a few oases the head would be delivered according to tlie 
diagnosis, but the back was not so delivered. This has caused us to study 
the mechanism involved. The mechanism is as follows: The head enters 
the pelvic inlet in an oblique diameter with occiput posterior. • The body is 
placed Avith the shoulders (bisacromial diameter) in the opposite oblique, 
or’thc transverse. In a normal or lypical occipitoposterior position, inter- 
nal anterior rotation of the occiput results. A rotation of the shoulders in 
the same direction as the occiput occurs, Avhich brings the shoulders finally 
into the same oblique diameter in Avhich the occiput was at the onset of 
labor. In an atypical occipitoposterior position internal anterior rotation 
of the occiput results. The shoulders are rotated as in the typical case and 
the occiput is born. Now the shoulders undergo further rotation, or super- 
I'otation, in the same direction and the bisacromial diameter is born in the 
same oblique diameter in AA’hich it Avas AA'hen the occiput entered, but AAuth 
the back anterior, i. e., the shoulder that A\'as anterior is delh^ered poste- 
riorly. Obviously the uterus must be primarily responsible for this rota- 
tion of the shoulders. 

Summarizing the Foregoing Discussion . — The postural tone of the uter- 
ine musculature is the basic factor concerned in determining the presenta- 
tion and position. The attitude of the head in the presence of normal 
eephalopehde relations is due to the integration of three factors, namely, a 
harmoniously contracting’ uterus, the resistance to egress, and the un- 
equallj^ balanced tAvo-armed lever that exists betAveen the A'^ertebral column 
and head. If the force transmitted tlu’ough the fetal spinal column is mis- 
directed by improper coordination of the upper uterine segment, or if the 
loAver uterine segment or cervix is mox'e atonic or yielding in one portion 
than another, the lever action aauII be modified or abnormal. The uterus, by 
rotating the fetal back anteriorly, assists anterior rotation of the occiput. 



RUDOLPH AND IVY: INTERNAL ROTATION OF FETAL HEAD 


91 


With the occiput right or left anterior, the levatores aiii, the decreased re- 
sistance of the vulval slit, and the larger anteroposterior diameter of the 
outlet may rotate the occiput anteriorly. With the occiput in a transverse 
or a posterior position, and given a well flexed head, and a uterus that is co- 
ordinating and contracting adequately, the A'ertex on striking the pelvic 
floor is deflected anteriorl3'’ in a sagittal plane and a two-arm lever action 
operates in a “vertical” plane to rotate the forehead posteriorly and the 
occiput anteriorlj^ about the vertex or oecipitoaltoid articulation as an axis. 

A mechanism for the typical and atypical deliverj^ of the shoulders in 
oecipitoposterior positions is offered. 

A brief description of the comparative anatomy of the pelvis and the 
comparative physiology of the uterus in labor has been given. The results 
of a roentgenographie study of the delivery of the fetus in the dog are re- 
ported. On the basis of our studies, we conclude that in ' ‘ lower animals 
the uterus is primarily responsible for placing the fetus in a dorsosaeral 
position for physiologic birth. 

Certain human obstetric observations are discussed which may be inter- 
preted as indicating that the uterus may rotate the trunk and head. 
Whether this is due to the existence of a uterine property of “spiral ac- 
tion” cannot be stated on the basis of the evidence at hand. 


REFERENCES 


(1) Quid, Sir F.: A Treatise of Midwifery, Dublin, 1742, Oli Nelson. (2), Sax- 
torph: Quoted by Leishman, leferenee 87. (3) Salary e$: Quoted by Leishman, 

reference 87. (4) Baudelocque, J. L.: Quoted by Leishman, reference 87. (5) 

Naegole, E. F. J.; Quoted by Paramore, reference 77. (6) Levret, 21. A.; L'Art des 
Accoueliements, od. 3, Paris, 1761, P. Pr. Didot, Le Jeune. (7) Biphy, E.: System 
of Midwifery, Philadelphia, 1841, Lea and Blanchard. (8) Bridolph, L., and Ivy, 
A. C.; Am. j. Obst. & Gyrmc. 19: 317, 1930. (9) Itndolph, L., and Ivy, A. C.: Am. 
J. Obst. & Gyneg. 21; Go, 1931. (10) Denman, T.: Practice of Midwifery, New 

York, 1821, E. Bliss and E. IVliite. (11) Darwin, C.: The Origin of Species, ed. 6, 
New ITork, 1872, Jlerrill and Baker. (12) Darwin, C. : The Descent of Man, Kevised 
Ed. New York, 1874, Merrill and Baker. (13) Jones, F. TV.: Arboreal Man, 1916, 
Edward Arnold. (14) Eertwig, E.: Manual of Zoology, translated by J. S, Kingsley, 
New York, 1912, Henry Holt and Company. (15) Wiederslteim, E., and ParTcer, 
ir. N.: Comparative Anatomy of Vertebrates, cd. 2, New York, 1897, Macmillan and 
Company. (16) Kingsley, J. S.; Comparative Anatomy of Vertebrates, Philadelphia, 
1912, P. Blakiston ’s Son and Company. (17) Schumann, E. A.: Am. J. Obst. 69 : 637, 
1914. (18) Schumann, E. A.: Am. J. Obst. 71: 1, 1915. (19) Allport, W. E.: Am. 
J. Obst. 66: 525, 1912. (20) Lillie, F. E.: Development of the Chick, New York, 

1908, Holt and Company. (21) Kaapp, B. E. : Anatomy of the Domestic Eowl. (22) 
Thompson, D. TF.: Nature 78: 3, 1908. (23) Marshall, F. E. A.: The Physiology of 



ual of Obstetrics, translated by B. L. Partridge, New York, 1884, NViffiam Wood and 
Company. (27) Porhenji, J. E.; Quoted by Bartelmez, reference 33. (28) v. Baer, 

C. E.: Quoted by Bartelmez, reference 33. (29) Coste: Quoted by Bartelmez, ref- 
erence 33. (30) KuUcr, F.: Quoted by Bartelmez, reference 33. (31) WicTcman- 

Quoted by Bartelmez, reference 33. (32) Patterson: Quoted by Bartelmez reference 
33. (33) Bartelmez, G. W.: Biol. Bull. 35: 319, 1918. (34) Aristotle: Quoted by 

Bartebnez reference 33. (35) Nathusius, m. F.; Quoted by Bartelmez, reference 33. 
(36) Landois: Quoted by Bartelmez, reference 33. (37) Konig-Wrathansen E ■ 

Quoted by Bartelmez, reference 33. (38) Erdmnn: Quoted by Bartelmez reference 




, 64 , 

■nr Bndoipi' it. 

p, o -nKCO^-'-'^J'. -i.^s ^ ^ the sevcc" 4 

pXl. C. S. -pelvis • shoM'n on aifEercn 

=^S5S?r==ggg?is§ 

’»t- „, ..»<■'»’•■ “• ’” 


RUDOLPH AND IVY: INTERNAL ROTATION OF FETAL HEAD 


93 


being 95 per cent of tlie pregnancies are carried out at some stage or other wtli the 
back anterior or in the dorsopubic position. 

The Selllieim experiments have shown that the curve of the canal plus the pelvic 
floor trough aro responsible for tlie rotation of tlie fetal head and back. 

Whether or not nterine action can rotate the baby depends on whether the bag of 
waters is ruptured. If the bag of -waters is intact I doubt if the uterus can act on 
the baby floating inside the bag of waters and rotate it any waj', anteriorly or 
posteriorly. With the bag of waters ruptured, the uterus contracts down on the 
fetus, often grips it tightly and may actually prevent its anterior rotation. The 
descent which is encouraged by rupture is responsible for whatever anterior rotation 
occurs. 

Dr. Rudolph made one statement to which I must take exception, namely that, 
when the head is delivered, the shoulders may be above the inlet. The curve of the 
sacrum is 12 cm. and from the tip of the sacrum to the tip of the stretched perineum 
12 cm. more making 24 cm. in all. As far as I know, no neck is that long and con- 
sequently no head could be delivered -ivith the shoulders above the inlet. 

DR. EDWARD L. CORNELL. — I rather hesitate to accept the statement that the 
uterus itself is capable of rotating the fetus, providing the bag of waters is intact. 
In exceptional cases it has been my observation that without any uterine contraction 
the fetus has rotated when the head is within the pelvis, but this has not been more than 
ten to fifteen degrees. If that is possible without a contraction, I would hesitate to 
say that the uterus itself can rotate a baby. 

That the fetus can change its position of its own momentum without uterine con- 
traction, I think is accepted. Spontaneous version is frequently seen in pregnancy and 
almost invariably the patient will tell you that at a certain time there was a great com- 
motion in the abdomen. It has not been my fortune to see spontaneous version but I 
have always felt the activity of the fetus had sometliing to do with rotation or with 
version. 

DR. E. W. EISCHMANN. — In woman, because of the upright position and the 
absence of a tail, the tail muscles of the lower animals have been changed to the 
muscles of tlic pelvic floor which give support to the pelvic organs. Dr. Rudolph 
stated that the uterine contractions cause rotation of the fetus, but is not a pivotal 
point necessary for this rotation, probably the pelvic floor? I agree with Dr. Horner 
that the pelvic floor plays a most important role in the mechanism of labor, because 
wo often find that in a multipara with a markedly relaxed pelvic floor there is no 
mechanism of labor at all, because the muscles of the pelvic floor are markedly 
separated and hence do not serve as a pivotal point for internal rotation, etc. 

Dr. Rudolph spealis of the longitudinal muscle fibers; there are none in the 
human uterus for the fibers are arranged more or less haphazardly and interlace and 
cross each other. 

DR. RUDOLPH (closing). — The work of Sellheim was based on purely mechanical 
principles of a double cylinder passing through a rigid curved canal. Dubois and 
Edgar’s experiments seemed to corroborate the mechanical principles -u-ithout at- 
tempting to evaluate the importance of the manner in which the directing force was 
directed. In labor we aro dealing with a physiologic process in which both the fetus 
and the genital tract consist of vital structures, so that the experiments of Dubois 
and Edgar and the experiments of Sellheim, Aloir and Young cannot be accepted as 
conclusive. 

Dr. Bacon asks, what is the mechanism? According to Howell, we do not know 
the mechanism of peristalsis, pendulum movement and segmentation of the gastro- 
intestinal tract. IVe accept it as a physiologic process irrespective of the mechanism 



94 


AJrERICAX JOURNAL OP OBSTICTRICS AND GYNECOLOGY 


involved. Tlic mechanism of flic uterus is based upon physiology, even if we do not 
know the underlying mechanism. 

We believe that the uterus by its coordination or incoordination will direct the 
longitudinal force in such a manner as to bring about flexion or deflexion. How 
does it occur? We do not know, neither do we know what brings about the onset of 
labor, but we accept the biologic knowledge that the onset of labor occurs in dif- 
ferent species after a certain period of pregnancy, 

Warnekros has demonstrated that the position of the fetal head is usually in some 
form of deflexion. Therefore, gravity or intrauterine pressure docs not play a marked 
role in the mechanism of flexion of the fetal head during pregnancy. With the onset 
of labor the fetal licad becomes flexed, which we must accept as being due to the 
uterine contractions in the normal mechanism of labor. This leads us to the promise 
that the distention of the uterus does not occur on account of the gromng fetus, but 
is a physiologic coordination of the growth of the uterus to the demands of the grow- 
ing fetus. 

If evolution has an}’ value in medical science, why should it not be related to 
obstetrics'? If the uterus in the lower animals has rot.atory power, why is it not 
logical to assume that perhaps the human uterus has retained that property? We 
have demonstrated that the pelvis 'was developed on account of physiologic demands, 
and that in the difTcrent species the mechanism of the delivery of the fetus was such 
that some vital structure had to determine the manner in -(vhich the fetus must be 
delivered. We believe tliat by the L.aw of Natural Selection the uterus has de- 
termined the mechanism by which the fetus is delivered in the different species, as 
well as in man. 

In normal labor the head enters the pelvis in the oblique diameter, in the main, 
but in contracted pelves it attempts to enter in the transverse diameter to allow the 
smallest diameter of the head to pass through the anteroposterior diameter by 
cither the biparietal or the bitempor.al diameter. In a generally contracted pelvis 
the head attempts to pass into the pelvic cavity in the oblique di.ameter because it 
is still the largest diameter. Nature economises the space in whatever manner it 
finds logical and that the directing active force is the uterus. 

Dr, Fischmann asks about the pivotal point for the mechanism of rotation. The 
pivotal point is any part of the, point of direction which comes in contact ■with the 
uterine ■\vall directly or indirectly through the liquor amnii in order to form two op- 
posing forces, and the angle formed ivill depend on -whether the head remains 
stationary or is rotated anteriorly or posteriorly. 

We believe that many cases are called disproportion on account of the deflexion 
of the head, which is due to the syndronm vc have presented and is based upon 
uterine dysfunction. Wilson in a recent number of the Journal of Obstetrics and 
Gynecology of the British Empire wites, “Disproportion is usuall}' the reason given 
when cesarean, section is performed in an .apparently normal pelvis and for some 
reason the head does not fit the pelvis '»vell. It may be correctly ascribed to a certain 
amount of deflexion of the head due to or associated -with imperfect functioning of 
the uterus.” Therefore, our problem as obstetricians is to determine the manner to 
correct the uterine dystocia and not by moans of increasing the number of cesarean 
section -whicli increases morbidity and mortality. 

We believe that through comparative obstetrics, we can study the physiology of 
parturition and as in the other branches of medicine apply that knowledge to the 
human uterus. We have considered too much the mechanical factor and should know 
more of the physiology of labor. 



THE RESPIRATORY FUNCTION OF THE DETACHED - 

PLACENTA 

G. M. Bbandau, B.A., M.D., Houston, Texas 

T he intercliange of gases tlirougli the walls of the chorionic villi, be- 
tween the fetal and the maternal bloods occupies a prominent place 
in placental physiology. Except for this, death of the fetus would (juiekly 
supervene. In this paper evidence is presented which, I believe, will show 
that after separation of the placenta from the uterine wall oxygen may 
continue to be received and utilized by'^ the fetal blood. 

A review of the histologic structure of the chorionic villi will serve to 
clarify the subject matter at hand, hence Avithout attempting a detailed de- 
scription of the form and development of the placenta a brief outline of 
the facts pertinent to the discussion is presented. The chorion consists of 
Dvo layers ; an outer trophoblastic layer, and an inner mesodei’mal layer. 
The trophoblast, in turn is made up of two layers; (1) an outer laj’-er of 
nucleated protoplasm without cell boundaries called the syncytiotropho- 
blast or syncytium, and (,'2) an inner layer of cuboidal cells called the eyto- 
trophoblast or laj’^er of Langhans. The early chorionic villi consist at 
first of solid outgrowths of the trophoblast reaching out from the chorion 
over all its surface. Later these finger-like processes are invaded by meso- 
blastic tissue which then forms the core of the villi. Accompanying the 
ingroAvth of mesoblastic substance is a system of blood vessels which in 
each villus consists, Avhen developed, of an afferent arteriole, a mesh of 
capillaries, and an efferent venule. The arteriole carries mixed but es- 
sentially venous blood from a branch of the umbilical artery to the capil- 
lary tuft where it is purified to return through the vein as arterial blood. 
Demonstration of the facts that the umbilical arteries contain venous 
blood and that the umbilical vein contains arterial blood, together with 
the consideration that compression of tlie cord or abruptio placentae 
causes fetal asphyxiation, prove that oxygen is supplied to the fetal blood 
in the placenta,^ and that adherence of the placenta to the placental site 
is necessary for the maintenance of the oxygen supply of the fetus in 
utero. After the second month the chorionic Aulli in contact with the 
decidua capsularis gi-adually undergo atrophy, while those in contact 
witli the decidua basalis grow and develop, forming numerous branches 
and ramifications as avcII as incz-easing in size. Into these branches the 
system of blood vessels is likewise projected. The blood in the capillaries 
then is separated from the mateimal blood in the intervillous spaces by the 
endothelium of the capillaries, the reticular mucoid stroma of mesoblastic 
tissue, the eydotrophoblast and the sjmeytium. At term the cytotropho- 

95 



% AMEKICAK JOURNAL OF OnSTOTEICS AXD CYXECOEOGY 

blast bas disappeared and the syneyfiiini lias become thinned ont into a 
narrow band. Tlirongh tbe.se layers intervening between the fetal and 
maternal bloods the interchange of gases takes place by osmosis or eel) 
activity, or botli ; although the prcpondei'ancc of evidence indicates that 
it is mainly or entirely by osmosis.- Water and nutritive materials also 
pass tlu'ough, and in the transference of protein substances in the form of 
amino acids, the vital action of the cells seems to ])lay a more important 
role, but for the present thesis the gaseous exchange is our chief concern. 

Soon after tlie birth of the baby the circulation in the cord ceases, the 
lungs at this time assuming the function of oxygenat ion of the blood. The 
pulsation of the umbilical arteries in the funiculus can no longer be felt 
and the activity of the ])iaecnta as a fetal organ is at an end. 

Tt has been observed in a few instances when a baby Avas born Avith the 
placenta and undamped cord expelled intact that the baby lived Avithont 
respiration or asphyxiation for some time Avhilc the circulation through 
the cord and placenta continued. Schumacher-’’ recently reported such 
a case in Avhich a fetus miscarried in the fifth month and never breathed, 
and no artificial respiration AA-as applied, yet the fetal heart beats con- 
tinued for fifty minutes. In reporting this case the author adA*anced the 
opinion that the oxygen present in the blood in the fetus, cord, and pla- 
centa at the time of expulsion Avas sufficient to .supply the needs of the 
fetus for the length of time specified, and that Avhen this Avas chemically 
exhausted the heart stopped beating. HoAvever, he also suggested the 
possibility of ‘ ' a sort of branchial I'cspii'ation ’ ’ by an intake of air through 
the placental villi, Avounds (Avound surface), and capillaries, maintaining 
the oxygen supply and the carbon dioxide AA-aste. An incident of similar 
nature is outlined in the folloAving ease I’eport. 

CASE KEPOKT 

The patient wis an uuniarrietl teacher, eolorcft, twenty years of age. She had not 
reported for any prenatal care or supervi.sion and at the time of her confinement was 
attended by an amateur mulAvife. L.abor canio on prematurely at about sis months. 
After the birth of the baby she bled rather freely, the attendants therefore decided to 
apply for medical aid in the further handling of the case. On arriA-al I inquired about 
the baby and Avas told it had been born thirty minutes before, so my attention Avas 
turned at once to the mother who was bleeding freely enough to demand immediate 
treatment. It Avas approximately fifteen to tAventy minutes or more before the con- 
dition of the bab}’ could be inA-estigated, or at a most coiisorA-ative estimate forty- 
five minutes after birth. The infant Avas at the foot of the bed loosely covered AA’ith 
bedclothes-, ou lifting tbese the OA-um Avas found to be intact, the bag of Avaters nn- 
ruptured. The sac Avas broken and the baby lifted out. The heart Avas beating 
strongly, the color AA'as normal and but little effort Avas required to induce respiration. 
The cord Avas clamped and severed. Breathing continued spoiAtancously hut Avas rather 
shallow and crying Avas AA-eak. The infant AA-as AA-rapped in cotton, kept Avarm hy ex- 
ternal heat, and supportive and stimulative measures Avere instituted. He lived tAventy- 
four hours, dying then because of re.spii-.ntory failure and jirematui-ity. Autopsy Avas 
not obtained. 



BRANDAU: RESPIRATORY FUNCTION OF DETACHED PLACENTA 


97 


COMMENT 

A case such sequence of events would never occur in a hospital where trained 
assistants are present to assume charge of a baby at birth, nor would it be likely to 
come about in a home delivery if the accoucheur were present during the second and 
third stages of labor ; hence the case history itself being unusual, certain conclusions 
are suggested by a consideration of the clinical data which would not be apparent 
in the ordinary case as usually conducted. 

In the first place, although the infant did not breathe for three-quarters of an hour, 
there was no evidence of asphyxiation nor of decreased or embarrassed heart action, 
BO that it is a necessary deduction that during this time the baby was receiving his 
required amount of oxygen. The amount of blood in a newborn baby of average weight 
is approximately one-eleventh of the body weight, or about 280 gm. The amount of 
blood in the cord and placenta varies and no record of the accurate determination of 
its volume or weight is available, however the ratio between the amount in the fetus 
and the amount in the cord and placenta is somewhat more than 2:1. After com- 
pression of the cord the fetus may survive for five to ten minutes, rarely fifteen, and 
very rarely twentj' minutes,'' so that were the amount of fetal blood in the cord and 
placenta equal to the amount in the fetal body we should not expect the fetus to sur- 
vive as long as three-quarters of an hour without leoxygenation of the blood. But with 
the usual length of time of survival, the cord and placenta would have to contain from 
four to five times as much blood as the fetus, whereas in reality they contain less than 
one-half as much. In cases of abruptio placentae with complete detachment, the 
length of time of survival of the fetus has not been determined, yet with the onset of 
symptoms violent fetal movements are felt by the mother and these are presumably 
the agonal struggles of the asphyxiated infant. 

In the case reported the fetal body metabolism was active at at least the basal rate, 
and oxygen must have been consumed yet the total volume of blood in the fetus, the 
cord and placenta would be insufficient to supply the requisite amount of the gas for 
the length of time specified without rcoxygenation. Therefore, we must conclude that 
the fetal circulation was receiving oxygen from some outside source. As the fetal 
organism v,’as consuming rather than generating oxygen the source of supply must 
be looked for in the cord or in the placenta. The cord was enclosed in the amniotie 
sac and surrounded by amniotie fluid, its blood vessel walls comparatively dense and 
these covered by a greater or less thickness of Wharton’s jelly and overlaid with a 
layer of ectoderm. Furthermore, even were it possible for oxygen to penetrate these 
structures only a small portion of the blood corpuscular surface would be exposed to 
it, hence oxygenation would be incomplete. This then leaves the placenta as the only 
source of the oxygen supply. Here we have the blood in the capillary meshes of the 
villi separated from the air by a single layer of endothelium, a small amount of meso- 
blastic stroma, and a thinned out syncytium; structures whose permeability to oxygen 
and carbon dioxide as exchanged between maternal and fetal bloods has long been 
recognized. Tliere is this difference however, that oxygen exists in the maternal blood 
in a combined form (oxyhemoglobin), and in the air as a free gas mixed with other 
gases. But the o.xygen in ox-j-hemoglobin is so easily dissociable that the oxygen tension 
is regulated by tlie oxygen pressure in the surrounding atmosphere just as though it 
were merely in solution,’ and transference of the gas is by dialysis through the inter- 
vening structures. The condition in the case discussed here is analogous to that ob- 
taining in the respiring lung where the blood in the capillaries is separated from the 
air by the thin walls of the capillaries themselves, a small amount of delicate connective 
tissue containing tlie capillary network, and the simple squamous epithelium lining the 
alveoli and alveolar air sacs. So a careful evaluation of the data presented loads to 



98 


AMERICAN JOURKAE OP OBSTETRICS AND GEXECOLOGY 


tlie concJusion that in this case a gascons exchange took place between the atmospheric 
air on the one hand, and the blood circulating througli the capillaries of the cliorionic 
villi on the other. 

The cause of the premature labor was not ascertained but the gross appearance of 
the placenta indicated no abnormality in its structure nor any disease of its tissues, 
and though generalisations are hazardous it seems justifiable to suppose that any 
normal placenta under similar conditions might function in the same manner. 

Scliumachcr’ in his paper points out the importance of the placental blood in im- 
proving the prognosis in aspliyxia or of threatened asphyxia of the newborn, and shows 
the value of his observations in supplying a hitherto unrecognized reason for not clamp- 
ing the cord in such cases while the circulation continues tlirough it, and also in 
pointing out the importance of starting artificial respiration before compressing the 
umbilical vessels. 

SUMJIAUY 

1. The passage of oxj’gen tlivongh the walls of the chorionic villi from 
the maternal to the fetal blood and of carbon dioxide from the fetal to 
the maternal blood have long been accepted by physiologists as proved 
phenomena. 

2. That the same interchange of gases may occur between the fetal blood 
and the atmospheric air after detachment of the plaeenta from the uterine 
wall is not so widely recognized. 

3. A case is reported in wliich the assumption of such a gaseous inter- 
change is requisite to a rational explanation of the sequence of events in 
the ease history. 

4. This function of the detached plaeenta maj^ have a practical applica- 
tion in the treatment and prevention of some eases of asphyxia neonatorum. 


REFERENCES 

(1) DcLcc, Joseph B,; Principles .nnd Practice of Obstetrics, ed. 4, Philadelphia, 
W. B. S.aunders Co. (2) noiocU, TrUliam JI.; Textbook of Physiology, cd. 10, Phil.a- 
delphia, W. B. Saunders Co. (3) Schumacher, S.; Aliinchen. med, Wchnschr. 77 : 313, 
1930. (4) Queries and Slinor Notes, J. A.M. A, 95: 1039, 1930. 

1422 MzmcAh Arts BuiI/Dikg. 


Boggan, B. H., and Wrigley, A. J.: Rupture of Ovarian Blood-Cysts Simulating 

Acute Appendicitis. Lancet 221: 106S, 1931. 

The authors report 13 cases of this condition, the right ovary was affected in 
ten. Tliey implj' tliat the ovarian liemorrhage is an e.vaggeration of the normal 
physiologic meclianism of the ruptnre of the Graafian follicle. The essential diag- 
nostic differences favoring ruptured ovarian blood-cyst are: the sudden onset of 
severe lower abdominal pain in relation to slight trauma; the good general con- 
dition of patient in spite of its duration; and marked lower abdominal tenderness 
without marked muscular rigidity. 

They advise exploratory laparotomy if the diagnosis is uncertain (usually) and 
recommend at operation enucleation of the hemorrhagic area. 

H. Close Hesseltine. 



THE BERCOVITZ TEST FOR PREGNANCY 
A Report op 260 Cases 
Arthur G. King, M.D., New Orleans, La. 

(From the Department of Olstetries, Tulane University Medical School, 
and Charity Hospital) 

T his investigation of the pupillary reaction described by Bercovitz in 
as a diagnostic aid in pregnancy, was undertaken on the obstetric 
service of Dr. E. L. King, in an effort to determine the reliability and value 
of the test. 

The teehnie as presented hy Bercovitz consisted of instilling into one eye of the pa- 
tient a few drops of her own blood. At first serum was used, but this was later modified 
to citrated whole blood. Pregnancy was indicated by cither a dilatation, a contraction, 
or an alternation of the two, in contrast with the other eye in which there was no change. 
His studies revealed that the patient’s blood was capable of producing the same reac- 
tion in the eyes of nonpregnant individuals and in rabbits and cats. Precautions had 
to be taken before the test that the pupils were equal in size, and that the two eyes were 
evenly illuminated by a soft yellow light. The quality of the light and its intensity were 
particularly stressed. Of 72 nonpregnant women, not one gave a definite positive test. 
In 72 observations on 68 pregnant women, 80 per cent showed a definite pupillary- 
change, 4 per cent a doubtful change, with the remainder giving no reaction. 

Gordon and Emmor’ partially confirmed the test, using citrated blood. Their results 
showed a positive reaction in 64 per cent of 90 pregnant women. Tliey made the state- 
ment, without data, that no nonpregnant woman gave a positive reaction. White and 
Severance’ performed the test on 58 pregnant women, of whom but 19 gave a positive re- 
action, and on 15 nonpregnant women, of wdiom 3 did respond positively. 

In tbe series, berewitb reported, citrated blood tvas used at first, but 
soon tbe teelmic was simplified by taking from tbe finger several drops of 
blood in an ordinary medicine dropper and transferring it directly to tbe 
conjunctival sac. Tbe light used tvas eitber a low power electric bulb in a 
darkened room, or else daylight tbrougb heavy yellow shades. The pupils 
were examined first for equality and reactivity, and the patient was forced 
to fixate on a distant point to obviate accommodation changes. 

The objections to tbe test are many. Fig. 1 illustrates tbe relative size 
of tbe pupils in the ordinary positive case. Tbe end-point is very hard to 
read, and tbe reaction, furthermore, is relatively transitory. Tbe matter 
of illumination is of such importance that tbe experimental error may be 
very large. There does not seem to be available any means of making pre- 
cise measurements or a permanent record, and hence the variable factor of 
the personal equation must be depended upon. The test is not adapted to 
individuals with dark eyes, particularly negroes. Herevdth are presented, 
liowever, tbe results of this investigation Avitb tbe technic in its present 
status. 

All three types of reaction pointed out by Bercovitz were observed. 
These appeared in from a few to thirty seconds and persisted from one to 

99 



100 


AJrERICAK JOURJsAL OF OBSTETRICS AXD GYXECOLOGY 


about three minutes. The relative frequency in 73 positive cases was as 
follows : 


Dilatation 

27 

Contraction 

2S 

Alternation 

IS 


In the series there were 307 eases of definitely pi'oved pregnancy, of 
which 93 came from the prenatal clinic and 14 from the gjmecologic wards, 
I’cprcsenting cither threatened or recent incomplete abortions. 

The patients were studied in respect to the folloudng details: age, 
parity, length of gestation, and nervous constitution. There wei-e several 
cases each of thyrotoxicosis, syphilis (both treated and untreated), dia- 



Fig. 1. — Showing the difference in the size of the pupils in the ordinarj' positive reaction 
of the BercoviU tost in pregnancy. 

betes, fevers of various origins, and toxemias of pregnancy. Neither the 
correctness of the result nor the type of reaction was influenced by any of 
these factors. 

Numerous positive tests Avere obtained as early as seven or eight weeks 
after the last menstrual period, often before pregnancy could be diagnosed 
clinically with any certainty ; these eases were all confirmed later, however. 
In tAVO eases negative results Avere obtained at eight Aveeks, AAuth positive re- 
actions appearing at the tenth and tAA'elfth Aveeks respectively. 

On the other hand an obseiwation Avas made that is disturbing statis- 
tieallj', namely, that in the same woman the test might be positNe on one 
occasion, negative on another, and positive again later, but Avith a different 
type of reaction. The conditions under Avhich the testing Avas done were 
almost identical, but the factor responsible for this variability and for the 
false negative reactions is as mj^sterious as the cause of the phenomenon. 

The results obtained with these ImoAvn pregnant Avomen are given in 
Table I. It appears that not more than two out of three pregnant women 
Avill give a clear-cut positive reaction Avith this test. 

EPINEPHRnSFE 

BercoAutz suggested that the reaction might be due to an epinephrine- 
lilre substance, and found that epinephrine (1-1000) when dropped into 



KING; BBRCO^^;TZ TEST FOR PREGNANCY 


101 


the eyes of the same series of pregnant women gave 76 per cent positive, 
2 per cent donbtfnl, and 20 per cent negative results. He noted that 2 of 
98 nonpregnant women gave a positive reaction. 

In this investigation, epinephrine gave no positive reaction in 40 non- 
pregnant women. Table II summarizes the results in 45 pregnant women. 
It is seen that the results with epinephrine were not nearly so good as with 


Table I. Beactions With Known Pregnant Women 




OB ST. 

GYNEC. 

TOTAL 

107 CASES 

BERCOVITZ 

72 cases 

GORDON & 
EMMETT 

90 GASES 

Positive 

61 

66% 

12 

73 68% 

80% 

64% 

Doubtful 

11 

12% 

1 

12 10% 

4% 

13% 

Negative 

21 

22% 

1 

22 21% 

16% 

21% 

Table II. Comparison of Results With Blood and Epinephrine in 




Pregnant Women 



BLOOD 




epinephrine 





positive 

DOUBTFUL 


NEGATIVE 

Positive 

(27) 


15 

0 


12 

Doubtful 

( 9) 


3 

3 


3 

Negative 

( 9) 


4 

0 


5 


blood, although the series is too small to discuss percentages. But in four 
of these pregnant patients in whom the blood was negative, and in three in 
whom it was doubtful, the epinephrine reaction was distinctly positive. 
On the other hand it was interesting to note that in four of the confirmatory 
positive tests, the tj^e of reaction was different. In general, contraction 
was noted as often as dilatation. 

The concept of the cause of the reaction being an epinephrine-like sub- 
stance does not appear to be tenable. The typical epinephrine reaction is 
dilatation. Consultation with several physiologists revealed the informa- 
tion that epineplu’ine ordinarily affects the pupil only in the presence of a 
lesion of the cervical sympathetic system and in some cases of glaucoma. 

PUERPERIXJM 

Bcrcovitz stated that the reaction disappears iir from three to seventy- 
two hours after labor. Unfortunately, in this investigation it was not pos- 
sible to follow in the wards all the women seen in the clinic. The results 
of 45 tests performed during the puerperium are given in Table III. 

Table III. Results of Tests Dubing the Puerperium 


6-24 HOURS 


0 


24-48 HOURS 


THIRD THROUGH 
NINTH D,AV 


12 


Positive 

Douhtful 

Negative 


1 

0 

4 


1 

4 

21 


102 


AHfERICAN- JOURNAL OF OBSl’ETRICS AND GYNECOLOGY 


Similar to the observation made in the prenatal clinic, one woman mth 
a threatened abortion gave no reaction before delivery, a positive six hours 
after delivery, and a negative reaction two days later. 

Two cases must be taken up separately as they have not been included in 
any of the tables because of the difficulty in classification. One woman had 
delivered thirteen months before, was lactating, and had not menstruated 
in the interim. She w'as definitely not pregnant, but gave a positive reac- 
tion. The other woman had given a positive reaction on the eighth day 
postpartum; three months later she gave a positive I'caetion, although of a 
different tj^pe. She had menstruated once in the meantime, and was defi- 
nitely not pregnant. These two constitute false positives and weaken the 
value of the test in situations where it is most needed. 

NONPREGNANT INDIVJDU.VLS 

The nonpregnant individuals were divided into three groups : gjmeco- 
logie cases, males, uivd normally menstruating young females. 

Of 26 gjmecologic patients, 5 with simple amenorrhea, 2 at the meno- 
pause, 2 with cancer of the cervix, and 17 with uterine bleeding where 
no decidual tissue could be demonstrated, all gave definitely negative 
reactions. 


Table TV’’. Results or Tests on Nonpregnant Indwiduals 



OYXEC. 

JtALES 

FE.^rALES 

TOTAL 


positive 

0 

0 

2 

2 

2% 

Doubtful 

0 

3 

s 

n 

10% 

Negative 

2G 

18 

49 

93 

88% 


On the other hand, of 20 men tested, only IS were distinctly negative. 
One man had a questionable contraction, and anothei’, on two different oc- 
casions, showed considerable activity in the tested pupil in contrast to the 
control pupil, although the reaction was not definitely positive. Bach of 
these two young men was of the nervous tjqje, without, however, any signs 
of endocrine disorder. 

Bercovitz, and Gordon and Enuner, failed to obtain a positive reaction 
in their noi'mally menstruating groups. It was felt for a time, particularly 
after the excellent results with the gynecologic patients, that a positive re- 
action definitely indicated pregnancy. The two special eases referred to 
above, and the reactions in the young men cast grave doubts on this hope. 
This was confirmed by a series of young women who were menstruating 
regirlarly, and who, by reason of intelligence, position, and training, could 
be reasouablj^ assumed to be not pregnant, although they were not ex- 
amined. They were studied in relation to nervous constitution, normality 
of catamenia, and the time of the test in the menstrual cjmle. None of these 
factors seemed to have affected the results. Some girls giving a doubtful 
reaction when menstruating, when reexamined a week or two later were 
definitely negative ; on the other hand, some girls giving a doubtful I’eae- 



KING: BERCOVITZ TEST FOR PREGNANCY 


103 


tion in the middle of the cjmle were negative when they menstruated. Of 
this series, 2 showed positive reactions and 8 gaA^e doubtful tests. 

The results are summarized in Table IV to which must be added the two 
false positive reactions at three months and thirteen months respectively 
after delivery. 

SUMMARY 

1. The value of the Bercovitz pupillary reaction in pregnancy, although 
it is exceedingly simple, is greatly impaired by the difficulty in reading the 
result and by the fact that much depends on the personal equation of the 
observer. 

2. In 107 cases of proved pregnancy a positive result was obtained in 
68 per cent, a doubtful response in 10 per cent, and a negative result in 
21 per cent. 

3. Epinephrine, 1-1000, will give similar reactions, to some extent. In 
7 cases out of 45, epinephrine gave a correct positive result when the blood 
test was either negative or doubtful. 

4. The reaction is not constant in the same woman at different 
examinations. 

5. The reaction disappears early in the puerperium in most but not all 
cases. 

6. In 108 tests on nonpregnant individuals there were 4 false positive 
responses and 11 doubtful reactions. 

CONCLUSIONS 

Prom the data presented here it must be concluded that the test, using 
the technic of Bercovitz, is not reliable enough to be of value in doubtful 
cases of pregnancy. The reaction is empirical in nature ; it lacks precision, 
and is liable to error in interpretation because of technical difficulties and 
the personal factor. 

On the other hand the phenomenon is interesting and merits investiga- 
tion in the hope that the exiilanation of it will throw more light on the 
physiology of pregnancy. 


REFERENCES 

(1) BercovUc, Z.: Am. J. Obst. & Gynec. 19: 7G7-77S, 1930: Tr. Sect. Obst. Gynec., 
& Abd. Surg. A. M. A. p. 77-86, 1930. (2) Gordon, A. J., and Emmer, S. IF.: Am. J 
Obst. & Gynec. 81: 723-4, 1931. (3) White, If., and Severance, A. 0.: J. A. M A 
9/: 1275-9, 1931, 



VARICOSE VEINS OP PREGNANCY® 

Norman J. Kilboorne, J^LD., Los Angeees, Cabip. 

TN THE city welfare clinics of Los Angeles for prenatal patients, directed 

by Drs. Boehm and Pott, it was found that of 110 consecutive patients, 
23 had outright varicose veins, and 27 liad teliangieetases of the legs. 
Thus the pregnancy patients had varicose veins in one case out of every 
five, and if we add teliangieetases, there were incipient venous dilations 
in almost half the prenatal cases. This indicates that varicose veins in the 
prenatal patient are a problem of importance. 

ETIOIiOQY 

Thei-e is a notion amongst obstetricians, dating from Pierre Dionis, 
1707, that these veins of pregnancy arc due to pressure by the pregnant 
uterus on the external iliac or common iliac veins in the pelvis, obstructing 
the venous flow.^ This notion is called in doubt b}' four considerations. 
First, the varicose veins have been reported as beginning early in preg- 
nancy before tlie uterus had enlarged and risen sufficiently to roach the 
external iliac veins.= Secondly, it has been reported that in eases where 
the fetus died in utcro but was not expelled, the veins regressed at once, 
before the uterine mass could have involuted sufficiently to relieve pres- 
sure on the iliac vcins.^ These two statements need verification by further 
observations bj' obstetricians. Thirdly, when the varicose superficial 
saphenous vein was entirely obstructed by a ligature in 3S1 patients, the 
veins were not made worse but were improved.^ If the whole trouble 
were caused by obstruction due to pressure by the uterus on the external 
iliac vein this could not occur. iVnd fourthly, the majority of pregnant 
patients in the early stages of vein distui'bance show small varices with 
a distribution scattered all over the legs, and not confined to the main 
tributaries of the great saphenous. Recently I saw in consultation a 
pi’imipara, pregnant for four months, with enormous varicose veins high 
on the side of the body over the right kidney region. They had been pres- 
ent before pregnancy as congenital anomalies but had become much worse 
since she had become pregnant. It would be difScult to explain their in- 
crease at this location because of pressure by the uterus on the iliac veins. 
All these eonsidei'ations point to some other cause. 

It is likely that this cause will be discovered through the study of a 
phenomenon which no one apparently has yet noticed : namely, that in 
pregnancy, venous dilatation is only part of a general dilatation of all the 
smooth muscle tubes of the woman’s body. There are four such smooth 
muscle tubes : the miillerian duct tube, the wolffian duct tube, the gastro- 

-*Read before the Los Angeles Obstetrical Society, February 9, 19S2. 

304 



kilbourne; varicose veins op pregnanct 


105 


intestinal tube, and the blood vessel tube. In pregnancy the smooth 
muscle in all four of these tubes loses its tonicity. 

In the Avolffian duet tube, the early dilatation of the ureters nms de- 
scribed by Cruvelhier= as early as 1843, and has been many times con- 
firmed. I quote from Olshausen,® Prutz,’’ Lohlein,® Carson,® Hofbauer,^® 
Seng,"’- Mandruzzatto"'" Gellhorn"® and Draper’" who report in almost 
identical words, as follows: 

‘ ‘ During pregnancy the ureters ahvays dilate. The dilatation is demonstrated about 
the eighth week and is very marked. The ureteral dilatation cannot be ascribed to 
pressure from the enlarged uterus because it has been observed in the first weeks of 
pregnancy. In a minority of the women the ureters, havmg once been dilated, return 
to normal, but in a relaxed state, after the ninth to twenty-fifth day postpartum. In 
the great majority the dilatation persists after the twenty-fifth postpartum day, and 
contuiues in a lesser degree over a prolonged period of time. Our studies have im- 
pressed us with the tissue factor of each individual woman.” 

Not only is there dilatation, but also a hypertrophy. Hofbauer has 
shown the stimulus of pregnancy leads not only to hypertrophy of the 
uterus, but also hypertrophy of the muscle in the trigone of the bladder, 
in the lower end of the uterers and in the vagina. There is this same 
hypertrophy of the muscle in the walls of the veins. 

In the gastrointestinal tube there is, in pregnancy, a similar loss of tonus 
in the smooth muscle. Gellhorn’® has found that the intestines like the 
uterus have a lowered tonus in pregnancy and Alvarez’® after work on 
animals finds there never was much question about the existence of a 
gradient from duodenum to ileum or about its reversal, or flattening in 
pregnant animals. Even the muscle of the gall bladder derived embryo- 
logically from the intestinal tube loses tonicity and power to contract and 
empt3\’'’ 

In the blood vessel tube, the arteries as far as blood pressure indicates, 
undergo this influence only slightly for reasons of obvious biologic neces- 
sity, but the tendency to dilatation of the veins is before you. Thus far 
in recognizing venous dilatation in pregnancy as a part of a generalized 
dilatation of smooth muscle we are on firm ground of fact. 

When, however, we turn to search for the explanation of this fact, the 
path is not clear. The fact that this loss of tonicity is not limited to the 
veins but is generalized, points to some physiologic influence. Meisen’® 
believes this is a toxemia of pregnancy. Possibly Henderson’s recent 
work’® may show some relation of the loss of smooth muscle tonus to the 
respiratory activity in pregnancy. The French clinicians, Sicard,® 
Gaugier,-® Delater,-’ and Forestiei’" have been convinced that it is due to 
a change in endocrine equilibrium. Forestier and Gaugier believe that 
It IS due to insufficiency of posterior pituitary secretion. Unfortunately 
the French seliool has shown inadequate proof of their position. 

In favor of such a hypothesis, I can gather only this fragmentarv 
ovidenco ; 



106 


A5IERICAK JOURNAL OF OBSTliTRICS AND GYNECOLOGY 


The posterior pituitary extract is probably more than a mere accidental 
content of the dead protoplasm of the pituitary, for Krogh"" has shown 
that in the horse it is constantly secreted bj^ the living pituitaiy into the 
blood stream through the iiiternal jugular vein. This secretion when in- 
jected artificially into the body, causes contractions in the muscle of such 
intillerian duct derivatives as the uterus and powerful contractions of 
such Wolffian duct derivatives as the rxretcr-'* and bladder.-® Although 
its action on the intestinal tract under abnormal conditions may be vari- 
able-® every practical clinician knows that in nearly every noi’mal in- 
dividual the bowel movements which follow its use point to intestinal 
contractions. There has been some evidence to show that it raises the 
tonus in the arteries and veins.-^ 

"We cannot conclude that just because it is probably secreted normally 
into the circulation, and because given artificially it causes contractions 
of smooth muscle, that therefore it is the normal physiologic stimulus to 
the tonus of these muscles. A beginning in this direction however has 
perhaps been made by Krogh working on the lower animals, who found by 
experiments on the capillaries and melanophores of frogs that in the case 
of the capillaries there is a substance circulating in the blood which does 
maintain the normal tonus of the smooth muscles in the walls of the capil- 
laries, and -without which the tonus is lost, and that this circulating sub- 
stance is identical with posterior pituitary secretion ! 

"When we turn for evidence to show that the action of the posterior 
pituitary secretion is diminished in pregnancy a number of experiments 
are significant. Knaus-® found in experiments on rabbits that in them 
it was possible after the eighteenth day of pregnanej’’ to induce an abor- 
tion with very small doses of j)ostcrior pituitary extract and ascribes the 
inertness of the uterine contractions in the first half of pregnancy to the 
hormonal action of the ovary neutralizing or paralyzing the hormone of 
the posterior pituitaiy. Broun is so confident of tliis lack of pituitary 
secretion during pregnancy that he administers it in cases of toxemias of 
pregnane}’'. Krogh=® found that although experiments with human blood 
were unsatisfactory, that its concentration seemed lower in the later stages 
of pregnancy than during labor. Finally Siegert-® in experiments on the 
excised uterus of rats and guinea pigs has shown that the follicular 
hormone which everyone now knows is present in the blood during preg- 
nancy in enormous amounts, cheeks or entii'ely nullifies the posterior 
pituitary secretion. 

I hope that I shall not be quoted as accepting this belief of the French 
school that disturbance in the endocrine balance causes venous dilatation. 

I am merely mentioning it as a hypothesis deserving further stud}'-. 

A new instrument for measuring venous pressure is being perfected 
by Eyster and this may enable us to determine directly the effect of pos- 
terior pituitary secretion and the hoi’mones of pregnancy on the veins. 



KILBOURNE: VARICOSE VEINS OP PREGNANCY 


107 


It is hoped that not only the pharmacologists bnt the obstetricians and 
urologists may cooperate to help to solve this problem. 

ROUND GARTERS IN PREGNANCY 

For many years obstetricians have warned the pregnant patient not 
to wear round garters lest they cause varicose veins. 

The question as to Avhether the obstetric patient should be warned not 
to wear round garters depends upon the direction of the blood flow in the 
superficial veins of her legs. If there is an important circulation in these 
veins upward, then it is right to forbid the Avearing of round garters lest 
they obstruct the upAvard flow and cause the veins to bulge beloAv the 
garters. On the other hand if the blood flow in the superficial veins is 
doAviiAvard in a hydrostatic dead Aveight away from the heart toAvard the 
feet, then the round garters are a very good thing for the patient, for they 
obstruct no upAvard fioAV and hold back the heaA'y doAimAvard pressure of 
blood AA’hieh Avould tend to bulge them out in dilatations. Experiments by 
Barber'‘“ brought contradictory reports but rather indicated that there 
is an upAvard floAV in the superficial veins. Fluoroscopic examination of 
the veins after the injection of lipiodol as a radio-opaque medium by Mag- 
nus, Sicard and McPheeters have shoAvn the flow emphatically doAvnward 
toAvard the feet. Schmier®^ has thought this might be an error due to the 
great Aveight of the lipiodol AA^hieh might carry it doAvuAvard against the 
direction of the blood floAV. He repeated this AA'ork with lipiodol especially 
prepared of a concentration to give a specific gravity equal to that of 
normal blood. His results AA'ith such a preparation shoAved that in some 
patients with varicose veins vis a tcrgo pressure from the capillaries slowly 
forced the blood upAvard against the dead Aveight of hydrostatic pressure. 
In other patients he found exactly the reverse to be true and the blood floAv 
in their superficial A^eins was doAA-nAvard, then through communicating 
A’-eins loAv in tlie leg to the deep veins, and thence upAvard. 

I liaA’e used uroseleetan (lopax) as a radio-opaque medium. I have ex- 
perimented mixing it Avith blood in a glass tube and find it diffuses, mixing 
Avith the blood, and does not sink through the blood. Fig. 1 shoAVs a nor- 
mal A'ein into AA'hich 1 c.c. of uroseleetan has been injected just above a 
A’alve. The vaWe has efficiently prevented direct dowuAvard floAv. There 
is some dowuAvard floAv by AA^ay of the communicating veins until numerous 
small valves are reached Avheu the doAA-UAA^ard floAV is lialted. There may 
be some upAvard floAV due possibly to the mere mechanical pressure con- 
veyed from the piston of the syringe but Avhatever upAvard flow there 
may be is at any rate a most feeble affair for although this picture Avas 
taken lialf a minute after injection the shadoAv of the uroseleetan in the 
vein is still there and has hardly moA^ed upward an inch. 

Further x-ray studies indicate that in the normal person in the stand- 
ing position tliere is very little upA\-ard Aoav in the superficial veins, and 



108 


AJtERICAX JOURNAL OF OBS'l’ETRICS AKD GY2CECOLOGY 


that there is a definite downward flow below the great Talvc in the saphe- 
nous just below the knee. During exercise the circulation, possibly up- 
ward, may be increased but veins are not distended by exercise. If a dis- 
tended segment of a normal or varicose vein is isolated between two rubber 
bands and the patient is a.sked to walk, the full superficial segment is soon 
emptied. The recumbent position is also unimportant in this problem, 
patients remove their garters when they go to bed, and the superficial veins 
always empty anyway. 



Fig-. J. Fig. 2, 


Fig. 1. — The circulation in the normal vein above the great valve shown twenty-five 
seconds following the injection of 0.5 c.c. of 33 per cent uroselectan. 

Fig, 2. — Downward flow in varicose veins of niultipara in the tenth montn, 
twenty seconds after Injection of uroselectan. Double positive Trendelenburg. 

The next picture (Fig. 2) shows the left leg in which there was a double 
Trendelenburg, which means that by a clinical test it had been shown that 
the valves of this leg were incompetent in both the superficial veins and in 
the veins communicating between the superficial and deep veins. The 
shadow in the leg even in the instant after injection is moving do%vnward 
fi’om the point of injection at the finger tip. There is no sign of any up- 
ward flow even though there was time for the circulation to pass upward 
before the finger was applied. 

This next picture (Pig. 3) taken one mmute and twenty seconds after 



IOLBOURNE: varicose VEIKS OF PREGNANCY 


109 


injection sliows tlie sliadow passing not only downward but tbroug'b a 
communicating vein with an incompetent valve into a straight deep vein 
by which it is now ascending rapidly upward. 

Fig. 4 shows the other leg in which there was a single positive Trendelen- 
burg, which means that clinical tests had indicated that the valves in the 
superficial veins were incompetent but that the valves in the communi- 
cating veins were competent. This picture taken immediately after in- 
jection shows no upward flow but a rapid downward flow in these super- 



Fis. 3. Fig. 4. 


Fig. 3, — Circulation through communicating vein and up into the deep vein in 
multlpara in tenth month, one minute and twenty seconds following injection of 
uroselectan. Double positive Trendelenburg. 

Fig. 4. — Downward circulation in varicose vein of multipara in the tenth 
month immediately following injection of O.C c.c. uroselectan. Single positive 
Trendelenburg. 


ficial varicose veins. Pictures taken twenty and eighty seconds later 
show the uroselectan scattered through varicose veins all around the leg 
to the ankle and still staying there. 

It should be evident that in this pregnant patient Avith severe varicose 
veins, in the standing position there Avas no upv'ard flow in these veins 
to be impeded by round garters. 

But can the round garters obstruct the upAvard Aoay in the deep veins? 


110 


A^rERICAN JOURNAL OF OBSTOTRICS AND CYXECOLOGY 


Again the answer is “no.” I know bccaii.se I have applied a tourniquet 
very tight, much tighter tlian a patient would think of wearing a garter, 
and yet the opaque medium is carried away in those deep veins so rapidly 
that it is difficult to take an x-ray quickly enough to catcli it on the plate. 
The deep veins are buried too deeply near the interosseous membrane 
under pads of thick muscle of the calf and thigh to be affected by the pres- 
sure of round garters. 



Pig. 5. — ^An old but effective relief of varicose veins. Compare the round garter. 

As far back as 1844, Colles invented a vein truss, wbieh was a spring, 
encircling the thigh like a hernia truss but witli the pressure pad over the 
saphenous vein near the fossa ovalis to relieve varicose veins by shutting 
off and thereby relieving the downward pressure from above. He noted 
that this was particularly useful in pregnant women.®- 

It was an old trick for years for clinicians treating varicose veins to 
apply strips of adhesive around the leg, like a firm, round garter. 

Complete obstruction of the superficial veins by ligation, has been 


KILBOURNE: VARICOSE VEINS OF PREGNANCY 


111 


known to improve tkem ratlier than to make them worse. It was practiced 
by Panins of Aegina, 660 A.D.,"* Ambrose Pare, 1579,^® by Velpean,®^ 
and Trendelenbnrg.=’“ Berntsen^ in patients with a single positive Tren- 
delenburg obtained improvement in 80 per cent by high ligature, and 
Jeannel obtained thus a complete cure in 28 per cent of 83 patients. Clos- 
ing off the lumen of the vein above, did not cause venous dilatation below, 
it cured the varicose veins ! More recently de Takats has been able to 
check the progress of the development of varicose veins in pregnant women 
by this same method.^'* 

The intelligent patient cannot help being confused when the surgeon 
specializing in varicose veins applies pressure over the veins, or even 
ligates them, while her obstetrician forbids the possible obstructive pres- 
sure of round garters ! 

It is conceivable that in patients with a tendency to edema, round 
garters may be tight enough to obstruct lymphatics and make the edema 
worse ; but I have been speaking of varicose veins. I want to mention 
also that superficial veins around the foot have a very active circulation 
upward. 

My own opinion is that in the normal person in the standing position 
round garters may have a theoretical effect in obstructing a sluggish up- 
ward venous flow through superficial veins; but I doubt whether this is 
of much importance. I have never found any evidence to prove that vari- 
cose veins have been so caused. In the patient who already has severe 
vai’icose veins, I am sure that round garters not only do her no harm but 
ma 3 " be of important benefit to her. 

The incontestable mass of evidence of cures of the veins, by complete 
obstruction by ligating the vein makes me reluctant to forbid round garters 
to pregnant patients who already have varicose veins. 

Did we never hear of straining out the gnat and swallowing a camel ; 
some obstetricians meticulously forbid round garters and then order 
an elastic stocking! 

TREATJIENT OF VARICOSE \'EINS IN PREGNANCY 

Objection to treatment of varicose veins in pregnancy is very old. 
Ambrose Pare wrote of them in 1579 “women with child are commonly 
troubled with them by reason of the heaping together of their suppressed 
menstrual evacuation. It is best not to meddle with such as are invet- 
erate for of such being cured there is to be feared a reflux of the melan- 
choly blood to the noble parts whence there may be danger of maligne 
ulcer, a cancer, madness or sulfoeation.” Pigeaux warned of a ease of 
abortion in a cook, following the bandaging of varicose veins.®'' 

It was therefore a .surprise when MePheeters'® had the courage to read a 
paper vigorously urging the injection of varicose A-eins of pregnancy. His 
paper was based on a series of 46 patients. IMost of them had had pain be- 
ginning in the fourth month of pregnancy, in some ease.s so severe as to 



112 


AJIERICJVN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


make tJiem partial invalids. IMost ivere treated within a period of ten 
days in the fifth month. Ninetj’-two per cent were relieved, and 89 per 
cent said that under similar circumstances they would wish their friends 
so treated. It was urged ; First, whatever relieves pain cannot he called 
meddlesome obstetrics; secondly, clastic stockings are unsanitary and 
linen mesh bandages will not stay on above the knee; thirdly, injection 
treatment is harmless and by obliterating the varicose veins ma}'' prevent 
the occurrence of phlegmasia alba dolens. 

If a pregnant patient is in serious pain or discomfort I see no objection 
to allowing relief bj^ the simple expedient of injecting the veins. As to 
the question of preventing milk log by previous varicose A'ein injection 
I Icnow by clinical experience that varicose veins do develop phlebitis 
noth a frequency not found in normal veins. However, phlegmasia alba 
dolens most often begins in the deep veins of the leg and later involves 
the superficial veins. General treatment of varicose veins of pregnancy 
as a proph 3 dactie against phlebitis would not be advised. 

In the majority of light cases it is preferable to wait till after delivery 
and see if the varicose veins will not regress spontaneouslj'. However, 
the treatment is indicated in patients with serious distress during the 
fourth to seventh months of pregnanejL 

2007 Wn, SHIRE BOUIiEVARD. 


REl’ERENCES 

(1) “Quand Ic cours do cc sana cst .arrctc pnrln grosseur do la niatrico • • • _• 
des raricos . . , Pierre Dioiiis q. b.v Warwick ; Tho KationnJ Treatment of Vari- 
cose Veins and Varicocele. (2) Note bj' Briquet: These de Paris 1824: Warwick as 
above also by Kasliimura: Virchow's Arch. 179: 373, 1903. (3) Sicard: Le Trait- 

raent des Varices p. 23. (4) Berntsen: Nordisk Med. Archiv. 62: p. SO, 1927. (5) 

Crtivelhicr : Traite d ’anatomic descriptive — ^Paris, 1843. (6) Olshattscn: Klin, vort 

f. Gyniik. 39: 15, 1892. (7) Bruts: Ztschr. f. Gebnrtsh. u. Gynak. 23; 1892. (8) 

Lohlcin: Ztschr. f. Gebnrtsh. u. Gyniik. 4; 49. (9) Carson, W. J.: J. Urol. 16; No. 

3, p. 167. (10) Eofhaucr, J.: Bull. Johns Hopkins Hosp. 13: No. 3, 1928. (11) 

Seng, M. I.: J. Urol. 21: 475, 1929. Seng believes that the congestion of the uterus 
and adnexa of pregnancy has an obstructive influence. (12) Mandrussato, F.: 
Clinica Obstetrica, Kome 32: GOl, 1930. (13) Gcllhorn : Aw. J. Obst. & Gtnec. 16: 

723, 1923. (14) Draper, 7F. B.: J. Urol. 26: 1, 1931. (15) q. by Aivarcs as below. 

(16) Alvares, TT. C.; Aw. J. Obst. & Gynec. 19: 35-45, 1930. (17) Eiggins, Big- 

gins and Mann : Anat. Eec. 37: 287-301, 1928. Surg. Clin. N. Am. 7: 1541-1554,1927. 
(18) Meisen: Personal communication. Warwick also quotes Kanotzi as noting an 
effect on the vein wall following such a toxin as diphtheria antitoxin. (19) Eender- 
son, r.: J. A. M. A. 97: 1267, 1931. (3) Same as above. (20) Gaugier, L.: La 

Presse Med. 39: 206, 1931. (21) Deleter, G., and Engel, Jt.: Presse Med. p. 19, 1931. 

(22) Forestier: J. A. M. A. 90: 1932, 1928. (23) Krogli: J. Pharmacol. & E.vper. 

Therap. 29: 177, 1926. (24) Schonduke, TV.: Ztschr. f. Urol. 23: 865, 1929. Foss, 

J, B.: J. Pharmacol, & Exper, Therap. 38: 451, 1930. (25) Hicoliior and Bick: 

Arch. f. Exper. Path. u. Pharmacol, p. 47, 1924, 101: 169 q. by Boss. (26) Griiber, 
C. M., and Pipkin, G. ; J. Pharmacol. & Exper. Therap. 37 ; 401, 1930. (27) Capps, 

J. A., and Matthews, S. A. : Transactions of the Association of American Physicians, 
1913. (28) Enaus, E.: Zentralbl. f. Gj-nak. 53: 1162, 1929. (29) Siegcid, F.: Kim. 

Wchnsehr. 10: 734, 1931. (30) Barker, F. F., and Shattara, F. I.: N. Y. State Med. 

J. 25; 162, 1925. (31) Sclmicr, A. A.: Am. J. Surg. 14: 431, 1931. (32) CoUes: 

Lectures on the Theory and Practice of Surgery, 1844, q. by Warwick. (33) Trendel- 
enherg : Beitr. z. Klin. Chir. 7; 195, 1890. {i^Berntsen as above. (34) de Takais, 
G., and Quint, E.: Surg. Gjmee. Obst. 50: 545, 1930. (35) Johnson’s transition 
1634: Maladies des Vasseaux 1843 ; q. by Warwick as above. (36) MePheeters, E. 0.: 
Lancet, October, 1931. 



CONGENITAL PNEUSIONIA OF THE STILLBORN AND THE 

NEWBORN'^ 

Joseph Kaldob, M.D., Bbooklyn, N. Y. 

(From the Department of Olstctries and Lahoratories of the Israel Zion Hospital) 

I N CONSIDERABLE numbers of stillborn as well as newborn children 
who do not survive more than a few hours after birth, sufficient cause 
for death is often not found. 

Thomson tried to ascertain tlic most prevalent pathologic causes of stillbirth 
by way of a ■widely distributed questionnaire but found that most .diagnoses ■\vere 
not made on the evidences of autopsies. The macroscopic findings of McDowell’s 
autopsies on stillborns ■were more illuminating however, inasmuch as he showed 
that 231/0 per cent of his cases died of pathologic conditions found in the lungs. 
Still more interesting is the report of Hook and Katz who reported that in twenty- 
two cases of congenital pneumonia, only two could be diagnosed on the gross patho- 
logic findings, whereas in the rest of the cases the evidences of pneumonia could be 
found only by microscopic examination. 

Within twenty-one months of the years 1929 and 1930, thirty-nine 
cases of stillbirths and early deaths of newborn children were surveyed 
bj'’ me with the follotving result : Six wex*e macerated fetuses "which did 
not lend themselves to further investigation. Nine were premature still- 
borns and did not show any other pathology save that of underdevelop- 
ment and marked general debility. Two were stillborns showing severe 
malformations of the central nervous system (encephalocele) and two 
cases revealed cerebral and intraperitoneal hemorrhages respectively. 

In 3 of the remaining 20 eases the lungs were of dark "walnut color, 
especially in their posterior aspect, liver-like in consistency and from 
the cut surface of these dark firm parts, a granular material could be 
scraped off with the Imife, so that the macroscopic diagnosis of broncho- 
pneumonia could be made. In these three cases unfortunately, no histo- 
logic examinations were done. However, in view of the fact that two 
were stillborn and one infant lived only seven hours, there can hardlj^ 
be any doubt about the fact that these three cases of pneumonia were of 
congenital origin. 

The remaining 17 eases were examined histologically and 9 out of 
this group were diagnosed as pneumonias. In the other 8 no inflam- 
matoi'v changes were present. The individual reports follow: 

C.\SE 1. — Tlie alveoli were disteuiled and filled witli serous exudate, massive 
amniotic materi.al and occasional desquanmted cells. The blood vessels and septa 
sliowed niargination .and beginning emigration of leucocytes. Diagnosis: aspira- 
tion, incipient pneumonia. 

Case 2. — Tlie lung was fairly well aer.atcd, but the alveoli were separated by 
broadened septa. The septa sliowed liypercmia and leucocytic infiltr.ation. [Many 

•Rc.aC before Uie Brooklyn Gynecolopic.-il Society on May C, 1932, 

113 



114 


ASIERICAN JOURNAL. OF OnSTETRICS AND GVNECOLOGV 


alveoli were plugged with cellular exudate. Similar exudate was present in the 
bronchi. Amniotic matter was found in the alveoli and bronchi. Diagnosis: aspira- 
tion ; bronchopneumonia. 

Case 3. — Identical irith the previous, but larger foci of pneumonic infiltration. 
Diagnosis: aspiration, bronchopneumonia. 



Fig. 1. — Distended pulmonary alveoli filled with amniotic material. 



Pig. 2. — section from a case of congenital pneumonia, showing a small bronchus 

filled wiUr purulent exudate. 

Case 4. — Only a few alveoli contained air,- the others were collapsed or tilled with 
cellular exudate, mostly of polynuclear kind. Many of these intraalveolar plugs 
enclosed amniotic material. The larger bronchi were filled -with purulent exudate in 
which amniotic material was present. Diagnosis: aspiration; coalescent broncho- 
pneumonia. 



ICALDOR: CONGENITAL PNEUMONIA 


115 


Case 5. — Diffuse hemorrhagic inflltration of the lung, with almost complete 
obliteration of the pulmonary structure was present. Numerous amniotic scales were 
embedded in the structureless substance. In some places there was an accumulation 
of cells, some of which were pol 3 -nuclear leucocytes, others wandering cells with 
distorted nuclei. Diagnosis; aspu-ation; hemorrhagic infiltration; focal broncho- 
pneumonia. 

Case 6. — Engorgement of the blood vessels and diffuse hemorrhagic infiltration 
of the lung tissue. The alveoli contained besides blood and desquamated cells also 
large amounts of amniotic material. Diagnosis: aspiration; hemorrhagic infarction. 

Case 7.— The capillaries as well as the larger blood vessels were engorged; 
the lung was partly atelectatic. The aerated alveoli contained some coagulated 
albuminous matter in which amniotic scales were seen. Diagnosis; atelectasis; con- 
gestion; aspiration. 



Fig. 3. — A section from a case of congenital pneumonia, showing catarrhal exudate and 
massive amniotic material in the alveoli. 

Case 8. — Only partly aerated lung tissue was seen. No evidence of inflammation. 
Amniotic matter was present in the alveoli. Diagnosis; partial atelectasis; 
aspiration. 

Case 9. — The capillaries and the larger blood vessels were engorged. There was 
no evidence of inflammation. Unusually massive amniotic matter was present in 
the alveoli. Diagnosis; atelectasis; aspiration. 

Case 10. — The alveoli were filled with desquamated epithelium and occasional 
leucocytes. Abundant amniotic material was also present and cellular infiltration of 
the septa. Diagnosis: aspiration; catarrhal bronchopneumonia. 

Case 11. — The lung was atelectatic almost throughout. There were a few alveoli 
however, containing a fibrinous exudate with a few leucocytes. Cellular infiltration 
of the septa was seen. Only a very few amniotic scales were found in the alveoli. 
Diagnosis: atelectasis; bronchopneumonia. 

Case 12. — Areas of atelectasis alternated with well distended alveoli. The latter 
wore plugged up with abundant amniotic material. There were only occasional 
cells within the alveoli. Diagnosis: aspiration; atelectasis. 

Case 13.— The alveoli were collapsed. The capillaries and the larger blood vessels 
were engorged. There was no amniotic matter in the alveoli. Diagnosis: atelectasis. 



116 


AJIERICAN JOUUK.Ui OF OBSTETRICS AKD GYI^ECOLOGY 


Case 14. — ^Atelectatic areas alternated with distended alveoli.' The latter con- 
tained albuminous coagulated material. Diagnosis; atelectasis; edema of lungs. 

Case 15. — The alveoli were mostly collapsed. The septa showed cellular infiltra- 
tion with polymorphonuclear leucocytes. A few amniotio scales were found only in 
the larger alveoli. Diagnosis; atelectasis; incipient pneumonia. 

Case 16. — .The lung was almost completely aerated. Abundant amount of amniotic 
matter was present in the alveoli. There were a few leucocytes in the septa but no 
exudate in the alveoli. Diagnosis; aspiration. 

Case 17. — ^Parts of the lung were similar to the previous one. In other parts 
however, there was extensive infiltration of the septa and the alveoli were filled with 
cellular exudate. The bronchi contained much pus and desquamated cells. Diag- 
nosis; aspiration; focal bronchopneumonia. 

Summarizing our findings tve observed that out of 39 full-term stiU- 
borns and early deceased children evidences of pneumonia were obtained 



Fig. 4. — ^Interstitial inflammation in a case ot congenital pneumonia. Broadened inter- 
alveolar septa infiltrated with polynuclear and mononuclear leucocytes. 

in 12. Nine •were diagnosed only by the microscopic examination, an 
incidence of 52 per cent, high enough to indicate the absolute advisability 
of examining histologically the lungs of every stillborn and early de- 
ceased newborn where the lack of gross autopsy findings leave the death 
unexplained. 

Amniotic matter, such as scales, fat and lanugo were found in various 
amounts in the bronchi and alveoli of 13 cases, that is, an incidence of 76 
per cent. These 13 cases included those 9 cases that showed evidences 
of pneumonia and 4 other eases where no signs of inflammation could be 
found. The fact that no case of pneumonia was observed which did 
not show the presence of aspiration material supports the belief that as- 
piration is, if not the sole, at least the most important etiologic factor 
in the development of congenital pneumonia. Farber and Sweet have 


KAIiDOR: CONGENITAL PNEUMONIA 


117 


sliown tlie relation of aspiration of amniotic sac contents to intrauterine 
asphyxia and report the presence of amniotic matter in 88 per cent of 
their cases. 

As to the pathogenesis of congenital pneumonia, Boehenski, droebel, 
Lubarsch, Viti, Durante, Menetrier and Touraine believe that the in- 
fection is a hematogenous one. Despite the fact that a diseased condition 
of the placenta or any lesion of the membrane could not be found by 
them, they base their theory on the fact that the mother has suffered 
shortly before or during labor from an infectious disease. Although 
bacteria may travel through the placenta (Eaineri) and eases are on 
record, as for instance that of O'Connor's, ^vhere a child died thirty 
hours after its birth from streptococcus pneumonia, whose mother was 
found to be suffering from sinus disease. Although the possibility of a 



Fig. 5. — Bronchitis, peribronchial, and perivascular distribution of the inflammatory 
process in a case of congenital pneumonia. 

blood Stream infection cannot be denied as in congenital syphilis, yet 
from the definite pathologic evidences as shown above, and will be dis- 
cussed further in this article, we believe that intrauterine pneumonia as 
a rule is not brought about by an infection through the circulation. 

In those cases that are reported in the literature where the mother 
has been suffering with bronchopneumonia or lobar pneumonia and on 
autopsy of the child a similar condition was found, the assumption that 
the child received an aerogenons infection immediately after birth can 
be entertained. 

According to Murit, the pneumonia toxins of the mother, upon reach- 
ing the fetal lungs through the placenta, may set up a susceptibility to 
bacterial invasion and of late Lauche explains the development of the 
unspecific congenital pneumonias on an allergic basis. 



118 


AIIERICAX JOURNAL OF OBSTICTRICS AND GYNECOLOGY 


The majority of authors however, as Silberman, Tingle, Lehman, 
Johnson, O’Connor, Hook and Katz, ct ah, favor the belief that seems 
also to us not only as the more plausible but also as the verified patho- 
genic cause. Namely, that most pneumonias in the newborn, develop 
intraiiterine and are of bronchogenic origin. 

For a long time the ciuestion was undecided as to whether the fetus 
performs any intrauterine breathing or not. Ahlfeld was the first to 
observe this occurrence with the aid of graphic tracings and Walz asserts 
that intrauterine breathing is a necessary aid to the fetal circulation. 
But Schmitt does not consider that the suction caused by the expanding 
and contracting thorax is of any proved assistance at all to the venous 
circulation in the adult, ajid it therefore seems of still less importance in 
the fetus. Present daj' opinion is, that under normal and healthy con- 
ditions intrauterine breathing of the fetus docs not occur. However, 
under abnormal circumstances it may manifest some irregular breath- 
ing and from that, aspiration will result unavoidablj*. Obstetricians 
are familiar with the short and snappj* inspiration that the child will 
sometimes draw on the intrauterine manipulation of the accoucheur’s 
hand. 

According to Bartholomew, Dyroff and others, the same factor that 
elicits the first inspiration and lusty eiy in the delivered healthy baby, 
may cause if present tuider abnormal conditions, untimely breathing. 
This factor is the CO 2 accumulation in the fetal cirexdation. An excess 
of CO 2 ill the child’s blood may result from reasons originating in the 
mother, placenta or cord. Circulatory disturbances of the mother, due 
to pneumonia, decompensated heart lesions, tuberculosis, anemia, drugs, 
anesthetics as Avell as tetanic contractions of the uterus, premature sep- 
ai’ation of the placenta, placenta previa, compression of a low implanted 
placenta by the baby’s head, infarct of the placenta, knots of or pressure 
on the cord and loops around the neck, all may raise the level of the CO 2 
above normal and become a stimulant to the respiratory center. This 
physiologic action of the CO 2 gains practical therapeutic application 
in Henderson’s treatment of asphyxia with “Carbogen,” which is an 
aeriform mixtui’e of 7 per cent CO 2 to 93 per cent oxygen. 

In our own 12 eases of congenital pneumonia Ave found the mother suf- 
fering from miti-al stenosis and asthma in 2 cases, the child born in 
breech presentation Avith the application of forceps to the aftercoming 
head in 3 eases, and in another 3 cases the labor Avas exceedingly pro- 
longed, haAdng from forty to sixty hours in the first and from tAA'enty 
to thirty hours in the second stage. In one case the child Avas born in 
asphyxia livida and in the 3 remaining cases the labor as Avell as the 
deliA^ery was normal and uneA'entful. 

Beside the fact that the child in utero may aspirate due to lack of 
oxygen, two pathologic findings are irrefutable proofs that congenital 



KALDOR: CONGENITAL. PNEUMONIA 


119 


pneuinoiiia is bronchogenic in origin. One is that aspirated matter, 
composed of liornified epithelial cells, fat, lanngo, meconium particles, 
is found in the bronchi and bronehioli as well as in the alveoli. The 
second is that these alveoli are no longer collapsed as in an atelectatic 
state but are opened up just in such a manner as the air pressure un- 
folds them in the course of breathing. It would be difficult to imagine 
that a hematogenous transmission of bacteria into an atelectatic lung 
should cause the evolution of the alveoli in the aforesaid manner. 

The larger bronchi as a rule rarely show any congestion or inflam- 
mation with mucopurulent discharge. The reason for this is probably, 
that the pathogenic agent, which besides being a chemical rather than . 
a bacterial irritant, reaches the lung tissue suddenly, passing through 
the bronchi rapidly. 

If signs of pneumonia are found in the stillborn, its intrauterine de- 
velopment is unquestionable and the designation of “congenital” is war- 
ranted. The same is vindicated if the pneumonia in an early deceased 
child is found in such advanced stage of its progress that it is incom- 
patible to the length of time the child has lived. As for example, in 
Cases 2, 4, 17, where the span of life rvas from four to seven hours re- 
spectively, yet the microscopic report showed the inflammatory process 
of undoubtedly longer duration. 

Hook and Katz term those pneumonias that are found in the stillborn 
as congenital pneumonia. Those that are found in the early deceased 
children and show findings of amniotie or birth canal matter they call 
aspiration pneumonias. They classify them in this manner in order to 
differentiate them from other aseptic pneumonias that develop from 
other reasons such as, infected umbilical cord, faulty respiration due to 
cerebral trauma or food aspiration caused by dyspeptic disorders. 
However, we differ with the designation of aspiration pneumonia in the 
case of the early deceased child whose cause of death lias been pneumonia 
with findings of amniotie fluid. We feel these pneumonias too were 
undoubtedly contracted intrauterine and therefore should also be termed 
congenital pneumonias. 

From a differential diagnostic point of view, pneumonia alba is not 
easily mistaken with congenital pneumonia. In the latter no chronic 
inflammatory changes of the septa, connective tissue proliferation or 
granulation tissue with chronic cellular infiltration of the vessels can 
be seen, nor can any spirochetes be found. 

We are not ready to answer the question with absolute assurance as 
to whether congenital pneumonia is the cause of death in the stillborn, 
because it cannot be determined to what degree the breathing surface 
of the lung can be impaired without becoming insufficient to maintain 
life, yet we feel that if it is the only ascertainable pathologic finding 
it shall be accepted as the cause of fatality. 



120 


AJIERICAN JOURKAL OR OBSI'ETRICS AXD GYNECOLOGY 


The clinical diagnosis of congenital pneumonia in the stillborn is of 
coui’se impossible. In short lived children eilher no constitutional re- 
action is found or symptoms of a more or less pronounced broncho- 
pneumonia are present. However, a presumptive diagnosis can he made 
if in conjunction with the auscultation and percussion findings, the 
history reveals such birth complications as have been enumerated pre- 
viously and especially so, if the child was born in asphyxia Imda or 
showed from the beginning embari*assed, irregular or weak respiration. 

The occurrence of congenital pneumonia in normal cases of child- 
birth, as in three instances of our sei-ies, where the labor was short and 
the delivery was void of any complications whatsoever, shall be note- 
worthy for both the obstetrician and to executives of forensic medicine. 
A thorough microscopic examination of the lungs may often absolve the 
obstetrician from rcs])onsibility in the stillbirth or early death of the 
infant and maj' also avoid serious errors of indictment in suspected 
infanticides. 

CONCLUSIONS 

1. Congenital pneumonia was found in one-half of the cases of still- 
born and newborn children that showed no other cause of fatality. 

2. Three-quarters of the cases showed the presence of aspiration mat- 
ter in the lung tissue. Because of the fact that such aspiration material 
was always present in the eases of congenital pneumonia, it is assumed 
that aspiration is responsible for the inflammation and together with 
atelectasis may be the cause of death. 

3. Congenital pneumonia is bronchogenic in the vast majority of 
cases. 

4. The advisability of a microscopic examination of the lungs of still- 
born and early deceased children is stressed. 


REFERENCES 

Ahlfeld, F.; Lehrbucli d. Geburtsh. 478, 1898. Ahlfeld, F.: Ztsolir. f. Geburtsli. 
u. Gynak. 61; 473, 1908. Ahlfeld, F.: Arch. f. Gyutik. 79: 211, 1917. Bartholomeiv, 
B.; Am. J. Obst. & Gynec. 6; 418, 1923. Bochenski, K., and Groebel, AT.; 
Monatsehr. f. Geburtsh. u. Gynjik. 22: 490, 1905. Durante, AL : Zentralbl. f. Path. 
4: 557, 1893. Dyroff, B.: Zentralbl. f. Gj-niik. 51: 967, 1927. Farher, S., and 
Sweet, L.: Am. J. Dis. Cliild. 42: 1372, 1931. Henderson, F.; J. A. M. A. 90: 
583, 1928. Hook, H., and Eats, K,: Virchow’s Arch. 267: 571, 1928. Johnson, 
W. G.; Proc. New York Path. Soc. 23: 138, 1923. Johnson, W. C.: Am. J. Obst. 
& Gynec. 9: 151, 1925. Louche, A.: Ztschr. f. Geburtsh. u. Gj-nak. 91: 627, 1927. 
Lehman, G.: Ai'ch. f. Gyniik. 78; 198, 1900. Luharsch, 0.: Virchow’s Arch. 123: 
70, 1891. McDowell, H. G.: New York State J. Med. 23: 143, 1923. Menetrier et 
Tonraine: Zentralbl. f. allg. Path. u. path. Anat. 19: 262, 1908. Mnrit, H.: 
Zentralbl. f. Gynak. 15: 1651, 1909. O’Gonnor, Ch. M.: Bull. Buffalo Gen. Hosp. 
4: 20, 1926. Baineri, G.: Zentralbl. f. Gynak. 13: 902, 1908. Schmitt, W.: Ztschr. 
f. Geburtsh. u. Gynak. 90: 559, 1926. Silhermann, 0.: Deutsche Arch. f. klin. 
Med. 34: 334, 1884. Tingle, Cl D.: Arch. Dis. Cliild. 1: 255, 1926. Thomson, 
Gh. J.; J. Obst. & Gynec. Brit. Emp. 33: 390, 1926. Viti, B.: Zentralbl. f. allg. 
Path. u. path. Anat. 2; 105, 1891. TTals, W.: Monatsehr. f. Geburtsh. u. Gynak. 
60; 331, 1922. 

75 Ocean Avenue. 



MENGERT : SUBA.CUTE BA.CTERIAL ENDOCARDITIS 


121 


DISCUSSION 

DE. CHABLES A. WEYMULLEE.— Every baby who has cyanosis must be 
suspected of having congenital pneumonia. Obviously intracranial hemorrhage 
and suprarenal hemorrhage must be considered as well. In an extensive clinical 
study of this type of lesion we have been able to collect about 60 instances. The 
only possible means of diagnosing them has been by the x-ray. Clinically, even 
though there are definite x-ray findings, no physical findings can be elicited. The 
collapse-sjmdrome found in the early days of life is no different in intracranial hemor- 
rhage, intrathoraeic lesions and suprarenal hemorrhage, or so slightly different that 
it is impossible to make a diagnosis. The question always arises, when there are 
abnormal shadows in the x-ray film, as to whether they are due definitely to an 
inflammatory lesion of this type, or whether perhaps they are due to aspiration 
of noninfectious material. It is entii-ely impossible, if the patient lives, to know 
whether that was true or not. Generally, we suspect that babies who have an 
intrauterine pneumonia will show a diffuse peribronchial density through the lung 
field, instead of the massive consolidations that are present in the so-called bronchial 
plug of atelectasis type. 

DE. JOSEPH KADDOE.— In regard to Barber’s and Sweet’s studies I desire 
to say that in their paper they simply show the relationship and find an associa- 
tion between atelectasis and aspiration. Eurthermore, they have developed a cer- 
tain staining technic with which they not only can show up these hornified epithelial 
cells, fat and lanugo in the alveoli, but also the vernix caseosa as a vernis membrane. 


SUBACUTE BACTERIAL ENDOCARDITIS AS A COMPLICATION 

OF PREGNANCY 

William F. j\'lENGERT, M.D., Philadlphia, Pa. 

(From the Department of Ohstetrics and Gynecology, State University of Iowa) 

'^HE infrequency of subacute bacterial endocarditis as a complication 
of pregnancy prompts the report of two cases occurring on the Ob- 
stetrical seiwice of the University Hospital during the past five years. 

Subacute bacterial endocarditis was first recognized as a clinical entity in 1852, 
Osler,“ in his Gulstonian Lectures based on a series of two hundred cases, credits 
W. S. Kirkes as the first to give an unmistakable account of the disease, while he 
himself first organized and gave a comprehensive picture of the entity. Subsequently, 
an enormous volume of writings on the subject has emerged from many pens. 

Blumer= notes that subacute bacterial endocarditis usually occurs in the third 
decade of life in patients who have had antecedent diseases producing heart damage, 
and seems to select those having well compensated valvular lesions. Its onset is in- 
sidious and the course prolonged, hence the name coined by Schottmiiller in 1910, 
“Endocarditis Lenta.’’ Although a streptococcus, usually viridans, is the infecting 
organism in an overwhelming majority of cases (95 per cent), a small number are 
caused by other organisms, chiefly the influenza bacillus. The outcome is almost 
always fatal in three to eight months. Osier emphasized the cardinal diagnostic fea- 
tures; fever, the existence of an old valve lesion, embolic phenomena, and positive 
blood cultures. These criteria are excellent, and with the possible exception of the 
history of an old valve lesion, should all be present to justify a diagnosis. 

In the light of these criteria most of the cases reported as complicating pregnancy 
are readily determined to be endocarditides of other types. Walser” gave an excel- 



122 


AJIKinCAN JOURXAT-. OF OllSTETRICS AXD GYNECOLOGY 


lent review of tlie literature iu 102S from the standpoint of preRnancy complication, 
added two cases, and said, “The only definitely positive case found was the case re- 
ported by Findley in which the causative orpanism was isolated “A re- 

view of some of the supposed cases, LoGendre," Burpess,* Norton," Caussade and 
LcRasle," shows them to he atypical. Osier V" four cases are not given in sufficient 
detail to enable one to .iudge of their true identity, and even Groom V case, though 
rather convincing from the standpoint of the anamnesis, is lacking in two particulars; 
proof of the causative organism, and of embolic phenomena : Kobaeker" and RckF re- 
ported undisputed cases in 10,^0. The available and definite reports of subacute bac- 
terial endocarditis accompanying jiregnancy are: Findley" 1921, AValser" 1928, EekP" 
1930, and Kobacker' 1930. To these .are added the following two. 

CASE REPORTS 

Case 1. — HVhite primigravida, aged twenty-one, was admitted to the University 
Hospital November 20, 1930, m the sixth lunar month of prcgn.ancy, app.arcntly in 
good health. The last menstru.al period occurred during the first week of May, 1930. 
The patient g.avc a history of scarlet fever at the age of five, and at fourteen ye.ars 
she had lobar pneumonia with cmp 3 'cma followed In' drainage and extremely painful 
swelling of the knee, ankle, wrist, .and elbow .ioints, necessitating a total period of 
six weeks’ bed rest. Three weeks after getting up she developed a cough, dependent 
edema, and became short of breath. Following recovery from this episode she re- 
mained well until the present time. 

Physical Kramhiation . — The patient was a well developed and nourished woman, 
normal except for a slightly enlarged thyroid, an operative scar on the right side of 
the thorax, and a markedly enlarged heart with the left border 15 cm, from the mid- 
sternal line. There was a double aortic murmur and the apex first sound had a slap- 
ping quality with a suggestion of presj'.stolic roughening. There was no edema of 
the extremities, moisture in the lungs, or anj' other sign of cardiac decompensation. 

Antcpnrtnm Course. — There was .a daih' remittent fever rising each evening as 
high as 100° to 102° F. Blood cultures taken December 13, 10, 22, and 26 showed 
nonhemolytic streptococci which grew both aerobicalh' and anaerobically. A cathc- 
terized specimen of urine on Januarj' G, 1931, showed chemical and microscopic blood, 
and small petechiae were found in the lower left con.iunctiv.a and on the right palmar 
surface. 

Labor . — On Januarj- 20, two months after admission, she wont into labor spon- 
taneouslj' .and after an eighteen hour first stage, controlled bj' energetic administra- 
tion of morphine and scopolamine, was delivered by breech extraction of a 2558 
gram normal female child. 

FostparUnn Course. — ^Immcdiateh' following deliver.v the patient’s temperature 
rose to 102° F. and during the rest of her postpartum course fluctuated between 
102° and 103° F. During the second week after delivery the spleen became palpable 
and tender and more petechiae were found in the conjunctivae. Examination on the 
seventeenth postpartum day showed normal involution of the pelvic structures despite 
the febrile puerporium. The uterus was about twice the size of the nonpregnant 
organ, and the adnexa and the parametria were free. Twenty-one days after de- 
liver 3 ' the patient was transferred to the medical service where her course was a con- 
tinuation of the immediate postpartum period. Blood culture again showed a non- 
hemol 3 'tie streptococcus. She developed an abscess of the left l.abium majus in the 
region of Bartholin’s gland and was returned to our service for its drainage. She 
was discharged March 4, 1931. 

Polloto-Up. — A letter from the patient’s home ph 3 'sician said, . • • After 

her return from the hospital I did not see M F until April 24. At this time 

she was suffering from an extreme degree of cardiac failure On Af.a 3 ' first 



mengert: subacute bagtebiau endocarditis 


123 


I saw her again on account o£ a small painful infarct of the left forefinger. Soon 
after this there were multiple infarcts, the most serious being into the right kid- 
ney The kidney was markedly enlarged and painful, and the urine was 

loaded with blood and easts of all descriptions.*^ The patient's father wrote that 
she died on May 18, 1931, sis months after her admission to the hospital. 

The babj' left the hospital in good condition and when last heard of, August 11, 
1931, was in good health. No blood cultures were taken. 

Case 2. — white, twenty- seven-year- old patient was admitted to the University 
Hospital September 5, 1927, in the ninth lunar month of her fifth pregnancy com- 
plaining of malaise, afternoon fever, and sweating for more than four weeks. She 
had been restless, had lost weight, and had pain in the right side of the abdomen. 
Her general health had been good, except for measles, parotitis, and tonsilitis some 
years earlier. 

Physical Examination . — The left border of the heart was 12 cm. from the mid- 
sternal line, and there was a loud rough systolic murmur at the apex transmitted to , 
the left axilla. The sclerae were definitely yellow. 

Antepartum Co7irse . — There was a remittent fever ranging as high as 103° H. A 
blood culture and a Widal test were negative. 

Labor. — On September 11, six da 3 's after admission, labor began spontaneously and 
was terminated after a first stage of six hours by breech extraction. The child was a 
normal 3006 gram female. 

Postpartum Course . — The temperature continued as high as before labor, but the 
remissions were less marked. Pour days after delivery the spleen was palpable and 
very tender, and there was tenderness over the left kidney region. Another blood 
culture taken at this time was negative. Pleurisy developed in the left chest and the 
patient showed a loss of memory. Eight days after delivery the urine became grossly 
bloody, and chemical and microscopic tests for blood were markedly positive. Two 
days later the edge of the liver was palpable and tender, and the patient was trans- 
ferred to the medical service. Blood cultures taken October 12, 17, 18, and 19 showed 
Streptococcus viridans. On November 1, 1927, fifty-one days after delivery, the pa- 
tient died. 

Autopsy . — November 1, 1927. Heart: The mitral valve had a group of cauli- 
flower, friable vegetations on each leaf. Spleen: This organ was enlarged, weighing 
610 gm. There was a recent infarction, 9 cm. at its greatest diameter, in the upper 
pole and several smaller infarctions, one of which had broken down to form an ab- 
scess. Kidneys: The left kidney showed an old depressed scar 3 cm. long, probably 
representing a healed inf arct. Genitalia: completelj' normal. Streptococcus viridans 
was grown from the vegetations on the mitral valve, and cultures taken from the 
heart’s blood showed the same organism. 

The baby was discharged on the twenty-eighth postpartum day apparently in good 
condition, and weighing 3524 gm. No blood culture was taken. 

COMMENT 

Each of these patients had the two most important features of sub- 
acute bacterial endocarditis, repeated positive blood cultures, and embolie 
phenomena. Case 1 satisfies all of Osier’s criteria, while Case 2 did not 
have definite evidence of previous heart damage. She gave a history of 
tonsilitis, measles, and parotitis, and had a mitral lesion on admission, 
but we have no certain loiowledge that the heart damage existed prior to 
the onset of her terminal illness. 

Curiously, both babies presented by the breeeh, but this was surely a 
coincidence. No blood cultures vrere taken from the infants, so it is im- 



124 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


possible to add to M^alsei'’s^’^ observation of placental transmission of tbe 
infecting organism. However, they survived and were normal in all re- 
spects as long as they were under observation. 

The infecting organisms were Streptococcus viridans, and a non- 
hemolytic streptococcus. 

In view of the grave prognosis of subacute bacterial endocarditis, we 
did not feel justified in Case 1 in interference of any sort, belie\ang that 
deliveiy by the most conservative means after full dilatation of the 
ceiudx, with plentiful use of morphine and scopolamine during the first 
stage, offered the best chance for the child without adding appreciably 
to the mother’s risk. We could see no advantage in abortion, belie^ung 
that the mother’s chance for survival would not be improved and that it 
was justifiable to await a limng child. 

Delivery did not affect the course of the disease materially, and neither 
patient developed infection of the uterus or parametria. This absence of 
involvement of the genital organs in tlie presence of a Imown blood 
stream infection is confirmed by Walser’s'’^ and Findley’s® cases. The 
patient whose case Avas reported by the latter rallied for two Aveeks after 
delivery, dying later in uremia, and neither of Walser’s^^ patients de- 
Amloped any evidence of uterine or parametrial involvement. Kobacker’s’’ 
patient Aims delivered by eesai’can section in a successful attempt to ob- 
tain a living child. The mother Avas in a desperate condition and died 
four daj’’s later. At postmortem examination the site of the uterine in- 
cision shoAved “extensive necrosis and infective degenerative changes 
with resultant loosening of the sutures.’’ 

Keid’s^- ease is not given in sufficient detail to add materially to these 
observations. His patient aborted at the fifth month of her sixth preg- 
nancy during the course of a febrile disease from which she died five 
months later. “Streptococcus Auridans A\ms present in the blood cul- 
tures both in life and at the necropsy.’’ 

CONCLUSIONS 

Subacute bacterial endocarditis does not seem to affect the course of 
pregnancj’', labor, and the iiuerperium materially. 

Pregnancy complicated by subacute bacterial endocarditis should be 
allowed to proceed to normal conclusion because the mother’s course is 
almost certain to terminate fatally, and it is extremely doubtful if sacri- 
fice of the child contributes, even in the smallest Avay, to her chance of 
surviAml. 

Delivery by the most conservathm means possible after full dilatation 
of the cervix with plentiful first stage analgesia is the obstetric treatment 
of choice. 

Cesarean section is justified only in the interest of the baby when the 
mother is in extremis. 

The babies seem to do Avell if they are not too premature at birth. 



greenhill: heart-block in pregnant women 


125 


references 

(1) Burgess: Lancet 1: 155, 1894. (2) Blmner, G 

(3) Caussade, G., and LeBasle, E.: Bull, et mem. See. 
902, 1924. (4) Groom, J. H.: J. Obst. & Gynee. Brit 
Findley, P.: Am. J. Obst. & Gtnec. 2 : 278-280, 1921 
Int. Med. 19: 367-380, 1917. (7) Kohadker, J. L.: S. 

(S') LeGendre, M.: Bull, et m6m. Soe. Med. d hop. de 
Norton, B. E.: Lancet 1: 162, 1910. (10) Osier, Wm.: 
1: 415-418, 459-464, 505-508, 1885. (11) TFalser, E. C 
840-846, 1928. (12) Reid, W. C.: J. A. M. A. 95; 1468- 


; Medicine 2; 105-170, 1923. 
med. d’hop. de Par. 48 : 895- 
;. Bmp. 10: 22-31, 1906. (5) 

. (6) Kinsella, R, A.: Arch. 

A M. A. 95 : 266-267, 1930. 
Par. 20: 949-952, 1903. (9) 

(Gastonian Lectures), Lancet 
.; Am. j. Obst. & Gynec. 15: 
■1472, 1930. 


HEART-BLOCK IN PREGNANT WOMEN 
J. P. Greenhill, M.D., Chicago, III. 

I N THE November, 1931, issue of the Amerxca.n Jobiinae op Obstetrics aetd 
Gynecology appeared an article on '‘Normal Pregnancy in a Patient "With 
Preexisting Complete Heart Block” b}' R. S. Titus and "W. B. Stevens.* The authors 
reported a ease of complete heart-block in a pregnant woman and stated they could 
locate published reports of only four similar cases that had been permitted to go 
through to full term. The purpose of my communication is to point out five addi- 
tional reported cases of heart-block, not all of whom had heart-block before preg- 
nancy supervened, and to place on record a case which recently came under my 
observation. 

The first case of complete heart-block complicating pregnancy which was reported 
in the literature was the one described by H. Breund* in 1918. His patient was an 
octipara who developed Adams-Stokes symptoms one and a lialf hours after having 
had a miscarriage. She died suddenly a few hours later with symptoms of complete 
heart-block. Autopsy revealed both an acute and a chronic endocarditis. The author 
had observed signs and symptoms of heart-block during the seventh pregnancy, but 
the patient had no symptoms during the interval between the seventh and the eighth 
gestations. Freund therefore was of the opinion that pregnancy and labor exercised 
a detrimental influence on the conduction system of the heart. 

The second case was reported by Walz* in 1922. A primipara was perfectly well 
until 1918 when she became ill with influenza and as a consequence of it developed 
heart trouble. From that time her pulse was very slow, and she had frequent faint- 
ing attacks. Not until she became pregnant did she notice any improvement. 'When 
first examined by Walz, the patient’s radial pulse was 40 per minute, whereas the 
venous pulsations in the neck were approximately 80 per minute. Pregnancy was 
uneventful and labor was easy and spontaneous. The first stage lasted five hours and 
the second only thirty-five minutes. The child weighed 3150 gm. (6 pounds 15 
ounces). During the puerperium the pulse never rose above 40 per minute. The 
patient left the hospital nine days after delivery. Electrocardiograms were taken and 
showed a complete heart-block. 

Another ease not included in Titus and "Williams’ paper, (most likely because 
their paper was written before this case appeared in print and because the heart- 
block did not manifest itself until after labor) was that reported by P. Herskovies' 
in April, 1931. A primipara had had polyarthritis at the age of fifteen, and since 
then had suffered with symptoms referable to the heart. During her pregnancy how- 
ever, she had no cardiac sjanptoms and her pulse was 84 per minute. She had a 
spontaneous labor and delivered a child weighing 2700 gm. (5 pounds 15 ounces). 
Fifteen minutes later the placenta was expelled. Twenty-five minutes afterwards 
the patient suddenly cried out, became pale, manifested epileptiform contractions of 
both arms and then became cyanotic. The pulse varied between 13 and 15 per minute 



126 


AMERICAN JOURNAL OP OBSTOTRICS AND GYNECOLOGY 


and in spite of all medication and mechanical efforts tlie patient died. At autopsy 
the only abnormalities found were in the heart. The heart muscle and the valves 
were normal but in the region of the Aschoff -Tawara nodes, at the opening of the 
coronary sinus was a small c.avitj- from wliich two drops of thick, yellowish, purulent 
secretion could be expressed. The probable etiology was a bacterial-metastatic or a 
rheumatic infection. This produced no disturbance during pregnancy but labor had 
such a deleterious effect on it that it caused fatal lieart-block. 

Two more cases of complete heart-block were reported by I^IcIlroy and Eendel“ in 
an extensive paper on “The Problem of the Damaged He.art in Obstetrical Practise.” 
The description of these patients is as follows: “Complete heart-block. Two pa- 
tients, one suffering from congenital heart disease and left bundle-branch block and 
the other from myocardial degeneration. Both these patients did very well, the first 
one not showing any signs of failure. The second patient had slight disability dur- 
ing her first pregnancy, but has .iust gone through another with verj’ few symptoms 
and has had twins. This patient however, had three Stokes-Adams attacks immedi- 
ately after deliverj-. ” 

Among the eleven cases reported in the literature (Freund, Walz, Jeannin and 
Clorc,‘ Laubry," Dressier, 2,’ Herrmann and King,* Ilcrskovics, Titus and Stevens 
and Mcllroy and Eendei, 2, there were two dcatlis (Freund and Ilerskovics). 

author’s case report 

Mrs. J. K., .1 primipara, aged thirty-five years, had a ncgati\-e family and personal 
historj- except that she knew she had an unusually slow pulse rate ranging around 
50 per minute. In spite of being married seven ye.ars, this was her first pregnancy. 
Her last menses began July 20, 1030, and conception was believed to have occurred 
on July 27. Quickening was observed December 10, 1930. When first seen by 
Dr. W. E. Brown of Cedar E.apids, Iowa, the patient’s pulse was only 50 per minute. 
Because of this he referred her to Dr. B. F. Wolverton who, from physical examina- 
tion and electrocardiographic studies, made a diagnosis of complete heart-block as- 
sociated with rheumatic heart disease and mitral insufficiency. The electrocardio- 
grams arc shown in Fig. 1. Because of the repeated fainting attacks and periods 
of marked bradycardia the patient was admitted to the St. Luke’s Methodist Hospital 
in Cedar Eapids on March 24, 1931. On admission the heart action was irregular. 
The apex and radial pulse rate averaged about 48 beats per minute whereas the 
jugular pulse rate was 90 per minute. The left border of the heart was 4i/^ inches 
to the left of the midsternal line. The apex was 4 inches to the left of the mid- 
sternal line in the fifth intercostal space. The right border was one inch to the right 
of the midsternal line. A diastolic murmur was heard at the apex and was trans- 
mitted to the axilla. The blood pressure was 110 systolic and 60 diastolic. The lungs 
were clear. The liver and spleen were not palpable. The uterus was the size of an 
eight months’ pregnancy, the presentation was O.L.A. and the fetal heart rate varied 
between 140 and 160 per minute. Tlie urine was normal except for the presence of 
acetone. The pelvic measurements were normal. 

After admission to the hospital, the patient’s condition became worse. She fainted 
more frequently, she was frightened a great deal of the time, and she was restless, 
dizzy, and weak. The pulse varied between 32 and 40 but the auricular rate re- 
mained around 80. An electrocardiogram showed complete dissociation. The blood 
pressure gradually rose. On April 7, the systolic pressure was 160 and the diastolic 
pressure 70 and on April 11, the systolic was 180 and the diastolic SO. There was 
no evidence of aortic insufficiency. Another electrocardiogram taken on Apj’il 9, 
when the blood pressure was 170 systolic and 76 diastolic revealed no changes. The 
QES wave in both tracings was 10 mm. Lead I showed no axis deviation and no 
conduction deficit in the bundle branches or tlie ventricles. At one time the pulse 
went as low as 18 per minute. The medication consisted of digifolin, barium chloride 



127 


GREENHILL: HEART-BLOCK IN PREGNANT WOMEN 

and adrenalin. On April 13 I was called to Cedar Uapids by Dr. Brown to perform a 
cesarean section. At the beginning of the operation the pulse was 52 and it re- 
mained almost the same throughout the operation. The blood pressure at the begin- 
ning was 150/80 and it varied between 142/80 and 180/84. I performed a trans- 
peritoneal, cervical cesarean section (laparotraehelotomy) and used local anesthesia 
not only for the cesarean section but also for the sterilization operation, which 
consisted of crushing and doubly ligating the tubes according to the Madlener pro- 
cedure. The baby which weighed 2310 gm. (5 pounds 1 ounce) was in excellent con- 
dition. Convalescence was entirelj'' uneventful. The patient was permitted to sit up 
in a chair ou the twelfth day after operation, and she and her baby left the hospital 
in good condition on the fifteenth day. During the puerperium the pulse varied be- 
tween 29 and 43 beats per minute and the blood pressure was normal. The highest 
temperature was 100.8° D. and this occurred on the third postoperative day. 



I aJU-/.. 


a-L—n 



nr 




— —£i — Zfi 

Fig. 1. 

COMMENT 

Heart-block complicating pregnancy is a rare and serious condition. 
Of tbe twelve cases reported in the literature including the case herein 
described, there were two fatalities, a death rate of almost 17 per cent. 
Undoubtedly many more cases of heart-block in pregnancy have been, 
observed but have not been reported. As Titus and Williams point 
out, heart block during pregnancj’’ is extremely rare in wmmen w^ho 
had the block before pregnancy supervened. Probably one of the 
reasons for this is that heart-block usually occurs in individuals over 
fbifj years of age. On the other hand, it is not very uncommon to 
observe heart-block during pregnancy, labor, or the puerperium as a 
temporary condition in women who do not have the heart-block at any 
other time. In every case of heart-block complicating pregnancy, labor, 
or the puerperium, a cardiologist should be called in consultation by 
the obstetrician. In patients with perfect compensation and without 
untoward ssnnptoms delivery through the natural passages should yield 



128 


AMERICAN JOURNAL OP OBSTETOICS AND GYNECOLOGY 


good results for both mother and child. The second stage should he 
shortened in primiparas by means of a low forceps operation under 
dii'ect infiltration anesthesia of the pei’ineuin and vagina. In Avomen 
with evidences of decompensation the low cervical cesarean section under 
local anesthesia before labor sets in is the safest procedure. 

I wish to thfink Dr. W. E. Brown for the details concerning the c.nsc .and .also for the 
e.'ceellent care he gave the patient after operation. 


REFERENCES 

(1) Titus, It. S., and Stevens, W. B.: Am. J. Obst. & Gvxec. 22; 773, 1931. 
(2) Frcnnd, H.: Ztschr. f. Gehurtsh. u. Gjnak. 30: 175, 1918. (3) Wah, If..- 

Zentralbl. f. Gyniik. 46: 1941, 1922. (4) JJcrslcovics, P.: Zentr.albl. f. Gynak. 55: 

1460, 1931. (5) Jeannin, A., and Clcrc, G.: Bull, et mem. Soc. mOd. d’hop, de 

Paris 51: 122, 1927. (6) Lauhry: Ibid, p. 126. (7) Dressier, IF.; Wien. Arch. 
Inn Mediz. 14: S3, 1927. (8) Jlcrnnann, G., and Kiny, E. L.: .T. A. M. A. 95; 
1472, 1930. (9) McIUroy, L., and Itcndcl, 0.: J. Obst. & Gynec. Brit. Bmp. 38: 7, 


185 Noutii Wabash Avkxue. 


SOME UROLOGIC COMPLICATIONS IN THE FEiMALE® 

G. Kolischer, M.D., Chicago, III. 

'^riE interest that gjmecologists in recent years have taken in urology 
makes it opportune to bring up for discussion a few instances where 
the results of modern investigations help to supplant routine treatment 
with rational therapy. Formerly and to a certain extent even today under 
the term incontinence was applied to clinical manifestations of entirely 
different origin. Now ive know how to differentiate pollalairia and impera- 
tive urinary frequency based on inflammatory processes of urination, from 
true ineontmenee based on insufficiency of the sphincter muscle. I am not 
going to discuss the extreme cases of complete incontinence Avhere on ac- 
count of total destruction of the sphincter transplantation of fasciae and 
muscles has to be resorted to, but will confine myself to those cases of rela- 
thm incontinence in which any increase of the abdominal pressure leads to 
dribbling or complete evacuation of the bladder. 

In juvenile individuals resistance gymnastics practiced with a straight 
urethral soraid as a rule is folloAved by good results. The resulting hj^per- 
plasia of the sphincter muscle may be evidenced by digital palpation, the 
strengthened sphincter muscle to be felt as a protruding ridge. 

In older patients AA'hose reconstimetive power is somewhat impaired this 
procedure may fail. Then Ave resort to a rather simple endovesical method. 
Employing an operative or eatheterizing cystoscope a fine electrode is in- 
troduced into the bladder and running a cutting current a few super- 
ficial incisions are made into the mucosa, these incisions extending about 
1 cm. into the bladder and reaching just as far into the urethra. "We use 
about the same technic as employed in the linear cei’vical incisions for 
endoeerAUcitis. It is adAUsable to establish these incisions in the upper half 


•Read at a meeting of the Chicagro Gynecological Society, March 18, 1932. 



129 


KOLISCHER: UROLOGIC COMPLICATIONS IN FEMALE 

of the so-called vesical neck and not in the vesical trigone, in order to avoid 
unpleasant after effects. If the first seance should, not prove successful, 
the procedure may be repeated. Local anesthesia with a 10 per cent novo- 
cain or a 4 per cent antipyrin solution makes this method absolutely 

painless. . 

Strictures of the female urethra although given more attention than 
formerly, nevertheless are quite often overlooked because the fact is lost 
sight of that their presence, location and extent may with certainty only 
be diagnosed with the help of an olive tipped sound. In this connection I 
would like to call attention to a complication which is rather frequent and 
if overlooked may cause pronounced inconvenience if a certain routine 
treatment is administered. It is common practice to follow dilatation of 
the urethra with instillation of concentrated silver salt solutions in order 
to alleviate the symptoms of a supposed cystitis. In fact in a great many 
instances one finds concomitant with stricture, a retrostrictural edema of 
the vesical trigone. The trigonal mucosa appears to be whitish and fluffed, 
imitating the appearance of absorbent cotton. Such a vesical lining is 
rather vulnerable and reacts very unfavorably to any caustic. Systematic 
dilatation of the urethra as a rule suffices to restore normal circulation and 
epithelialization. In stubborn cases medical diathermy is very helpful in 
restoring normal conditions. 

Gonorrheal urethritis in the female quite often subsides spontaneously 
if reinfection is avoided, but occasionally it may assume a chronic char- 
acter, thus not only being bothersome but also furnishing a fruitful source 
of infection for other pelvic organs. "Whenever one encounters a chronic 
urethritis with copious discharge urethroscopic examination should be 
undertaken. In such instances one finds disseminated granulations of the 
urethral mucosa generally located over the opening of the urethral glands. 
Scrapings of these granulations demonstrate a meshy structure whose 
cavities are filled with gonococci, explaining the stubborn character of 
urethritis of this kind. Electric destruction through an urethroscope 
furnishes prompt and lasting relief. 

Another source of great annoyance are varicose veins in the vesical 
mucosa. Sizeable varicosities may not only be productive of submucous 
and open hemorrhages but in many instances cause intolerable itching 
sensations within the bladder. This symptom may be explained by the 
slowing up of the local circulation and also by the loss of the epithelium 
over the venous nodules similar to the sensations around surface varicosi- 
ties. ^ Formerly these varicosities were not amenable to endoscopic therapy 
and in extreme cases one had to resort to cystotomy and excision or destruc- 
tion of the dilated veins with the actual cautery, either one an operation of 
importance. Nowadays we are in a position to obliterate these nodules by 
applying the high frequency current through a cystoscope, a simple and 
safe procedure the same as the destruction of a benign papilloma. Local 
or sacral anesthesia guarantees a painless procedure. 



130 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


Omission of cystoscopic and functional examination may in another in- 
stance he responsible for a therapeutic error. It is a rather common occur- 
rence that especially in young females during the course of a toxic or bac- 
terial nephritis, submucous liemorrhagie patches are established in the 
vesical mucosa, which are apt to pi'oduce various disagreeable symptoms. 

If these conditions are not recognized and, as is so often the case, urotro- 
pin or similar drugs are administered, the whole situation is aggravated. 
In some individuals such medication is apt to produce vesical hemorrhages 
though nephritis may not be coexistent. But if such patches are ab’ead}" 
present this medication accentuates the pathology and pronounced hema- 
turia with concomitant extensive loss of epithelium is apt to occur. In all 
instances of this kind antinephritic regime has to be instituted and any 
local treatment of the bladder has to be omitted. 

In doing prolapse operations or hj'sterectomies, the operator may miss 
the proper cleavage and open the bladder wall while freeing the idseus from 
its attachment to the porfio. The resulting interference with the circula- 
tion produce then areas of epithelial desquamation in the base of the blad- 
der, causing disagx-eeable S3^mptoms. If without cj’^stoscopic control the 
usual diagnosis of postoperative cj’-stitis is made and instillations with ir- 
ritating solutions are administered the syndrome is aggravated. The 
epithelialization of these defects takes place spontaneously as soon as 
proper circulation is reestablished. Mild diathermic treatments are apt 
to accelerate this restoration. It seems that in prolapse operations the de- 
tachment of the bladder not onty from the cervical junction but also 
laterally from the broad ligaments is of importance. In order to dispose 
of the retention in an extensive cystocele it seems to be necessary to bring 
the entire bladder under the influence of abdominal pressure. If however 
the lateral detachment of the bladder is neglected, a double saddle bag for- 
mation of the bladder will result. In this waj’' urinaiy retention with all 
its undesirable sequelae will be the result. 

The troublesome occurrence of pyelitis in the female has become some- 
what mitigated, by the introduction of intravenous urographjL This en- 
ables us to visualize the urinary ways without the vitiation by artefacts 
produced bj’- retrograde pyelogi’aphy. Systematic revision of the results 
obtained by pelvic lavage in pyelitis lead some observers to the conviction 
that this method is only indicated and successful in the instances of a 
dilated pelvis. Visualizing the renal pelvis by retrograde pyelography 
does not enable us with eertaintj’’ to differentiate a dilated pehns from a 
dilatable one. In the latter instance repeated instrumentation is apt to 
produce irritation and aggravation of the sjTnptoms. This is espeeiallj'' 
true in pregnant women. 

Another item may be mentioned which though not strictlj^ urologie in 
the usual sense in medicine, is the occurrence of certain nephrotic condi- 
tions. The latter constitute most of the renal disturbances in pregnant 
women. As a rule they do not constitute an indication for interruption of 



URNER: ACUTE INVERSION OP PUERPERAL UTERUS lol 

pregnancy and nsnally will subside under proper regime after delivery. 
The term nephritis is used for capillary toxicosis of the kidney and its 
sequelae, while the pathologic renal substratum in nephrosis is degenera- 
tion of the tubular epithelium without involvement of the glomeruli. Ne- 
phritic conditions are characterized by the retention of the organic meta- 
bolic end products, nephrosis is accompanied by disturbances of the lipoid 
economy of the body and the retention is confined to the inorganic end 
products. Nephritic edema contains proteins and no chlorides, nephrotic 
edema is characterized by high chloride contents without proteins. In 
gynecologic operations nephrosis may assume great importance. For some 
as yet unaccountable reasons nephrotic patients are very prone toward the 
establishment of pneumococcus infections. Perfectly clean laparotomies 
may in such instances lead to death on account of postoperative pneumo- 
coccus peritonitis. Timely diagnosis and appropriate treatment may pre- 
vent such inf aust accidents. 


THE USE OF ADRENALIN IN THE TREATMENT OF ACUTE 
INVERSION OP THE PUERPERAL UTERUS, WITH 
REPORT OP A CASE 

John A. Urner, M.D., Ph.D., Minneapolis, Minn. 

(From the Ohstetrical and Gynecological services of the General Eospital and the 
Department of Obstetrics and Gynecology of the University of Minnesota) 

'^HE work of Huntington, Irving and Kellogg (1928) and the recent 
paper of Irving and Kellogg (1931) upon the reposition of the 
acutely inverted puerperal uterus by laparotomy, has again called at- 
tention to this serious complication of labor. 

Because of the rarity and the high mortality of the condition, as shown 
in Findley’s (1929) recent paper, it would seem justifiable, in spite of 
the fact that a large series of cases is not available from which one could 
draw definite conclusions, to report any adjuncts to the- accepted method 
of treatment. 

It is admitted that the greatest immediate danger in the treatment of 
the acutely inverted puerperal uterus lies in attempts at replacement 
through a contracted cervix, in the presence of shock that almost always 
accompanies the condition. The generally accepted procedure is to 
control bleeding, replace the uterus in the vagina and treat shock by all 
available means, with the idea that later the replacement may be car- 
ried out with minimal danger to the patient. 

It has been pointed out, however, by Findley and others that this delay 
may result in contraction of the cenus and subsequently defeat all ef- 
forts at replacement. The contracted cervix, then, presents a barrier 
to either manual or operative replacement. The treatment must be 
directed toward an alleviation of this spasm of the cervix when the pa- 
tient is in condition to withstand the trauma of replacement. 



132 


AMERICAN JOURNAL. OP OBS'LETOICS AND GYNECOLOGY 


Kucker (1025, 1927, 1931) lias described the effect of adrenalin upon the Iniman 
uterus and has shown that 5 minim doses of 1-1000 solution caused a cessation of 
labor pains for a period of nine to thirty minutes in 16 out of 20 patients. In 
addition, he had used adrenalin successfully in the treatment of contraction ring 
dystocia and in difficult deliveries demanding uterine rela.vation. 

Jludolph and (1930) have demonstrated that adrenalin injected into dogs in 
labor, produced a temporarj' relaxation of the uterus Avhicli lasted for three to ten 
minutes. They also found that it inhibited the contractions produced by ergotamine 
tartrate and pituitrin. 

I'T. Hartman and Koff (1031) in experimenting with the ante- and postpartum 
uterus of the monkey found that the injection of adrenalin produced a single uteruie 
contraction which was followed by a relaxation period of five minutes or longer. 
They confirmed tlio work of Budolph and Ivy as to the effect of adrenalin upon the 
contractions induced by pituitrin. 

With the foregoing in mind the follotving case report is submitted; 

Sirs. E. O,, aged twenty-five, para ii, gravida iii, was admitted to the obstetric 
service of the General Hospital at 8:00 A.M., in early first stage labor. The cervix 
was about 2 em. dilated and the membranes had ruptured before admission. 

Physical examination revealed no abnormalities. The pelvic measurements were 
adequate. The position was O.L.A. P.oins were moderate but continued with in- 
creasing intensity and duration until 9:00 r.M. when she went into second stage labor. 
At 11:42 p.M. sho was delivered of a normal living child. There was minimal 
blooding after the second stage wliich was controlled by gentle massage of the uterus. 

At 12:05 A.M. there was a sudden liemorrbage in which approximately 1500 c.c. 
of blood were lost. An attempt was made to massage the uterus to contraction to 
permit Credo expression when it was noted that the placenta, membranes, and 
uterus were at the vaginal outlet. The patient wont into shook as her blood pressure 
dropped to SO syatolio. No diastolic reading could bo obtainocl. Her pulse in- 
creased to ICO and was hardly perceptible. The placenta and membranes had to 
bo separated in order to replace the uterus into the vagina. At this time the cervix 
was found to bo contracted down to about 3 cm. in diameter. The patient was 
quickly placed in Trendelenburg position and pituitrin and caffeine sodium benioatc 
w'ere given. External heat was applied. The bleeding at this time had stopped; 
1500 c.c. of saline were given intravenously which raised the blood pressure to 
110/60. The pulse rate lowered to 140 and was of fair quality. 

The patient was transfused with 550 c.c. of whole blood. The blood pressure 
rose until at 1:00 p.m. it was 138/90. Tlie pulse had slowed to 100. Her condition 
had greatly improved. 

At 1:00 P.M., thirteen hours after tho inversion, the patient was surgically pre- 
pared for manual replacement of the uterus. Atropine sulphate gr. 1/150 was given 
preparatory to gas-ether anesthesia. She was cathetcrized. Eive minutes before 
the vagina was entered % c.c. of adrenalin was givcir intramuscularly. The blood 
pressure rose to 140/88, the pulso increased to 120. Vaginal examination showed 
the uterus to be firmly contracted and the cervical ring not more than 2 cm. dilated. 

It had the consistency of cartilage. Pressure in tho sulcus gave little hope of re- 
position. Steadj' pressure was made against the inverted fundus with closed fist 
and within one minute (six minutes after tho adrenalin was given) , it began to soften 
on its posterior surface. The cervix relaxed to about 4 cm. in diameter. At this 
time (1:25 p.m.) an additional % c.c. of adrenalin was given. The blood pressure 
remained at 140/88 and the pulse rate at 120. VTithin one minute the cervix re- 
laxed enough to admit the closed fist and without further difficulty the uterus was 
completely replaced. An intrauterine pack was placed by hand. The blood loss 
during the operation was not more than 150 c.c. ' 



HERSH: LARYNGEAL DIPHTHERIA 


COMPLICATING PUERPERIUM 133 


Immediate transfusion of 450 c.c. of Tvliole Wood %vas given. The pack was re- 
moved in twelve hours. During the puerperium the temperature rose to 100.2 on 
the second, third, and fourth days. The patient was discharged from the hospital 
on her sixteenth postpartum day with a well involuted uterus and in good general 
condition. 

SUMMARY AND CONCLUSIONS 

The intramtisciilar iujeetion of adrenalin in this case of acute in- 
version of the puerperal uterus seems to have been elfective in producing 
relaxation of the uterus and cervix and to have greatly facilitated 
manual replacement. There is little doubt of its value in protecting the 
patient from further shock during operation. 

It is suggested that adrenalin is a valuable adjunct in the reposition 
of the acutely inverted puerperal uterus by either manual or operative 
method. 

REFERENCES 

(1) Biicfcer, M. Pierce; South. M. J. 18; 412, 1925; Am. J. Obst. & Gynec. 
14: 615, 1927; South. M. J. 24: 258-263, 1931. (2) Euntington, J. L., Irving, 

F. G., and Kellogg, F. S.: Am. J. Obst. & Gynec. 15: 34-39, 1928. (3) Findley, 

Palmer: Am. J. Obst. & Gyneo. 18: 587-591, 1929. (4) Fudolpli, L., and Ivy, 

A. 0.: Am. J. Obst. & Gynec. 19: 317-335, 1930. (5) Ivy, A. C:, Eartman, Carl G., 
and Koff, Arthur: Am. J. Obst. & Gynec. 22: 388-399, 1931. (6) Irving, F. C.i 

and Kellogg, F. S. : Am. J. Obst. & Gynec. 22 : 440-441, 1931. 

2615 Pakk Avenue. 


A CASE OP LARYNGEAL DIPHTHERIA COMPLICATING THE 

PUERPERIUM 

J. Hersh, M.D., Pittsburgh, Pa. 

TC'REQUENT mention is made in the literature of puerperal diph- 
theria, diphtheritic patches being found upon the denuded portions 
of the vulva and vagina. These are usually a primary genital infection 
and texts refer to them as sometimes being secondary to diphtheria of 
the throat. However, a search of the literature for cases of pharyngeal 
or laryngeal diphtheria complicating the puerperium reveals infrequent 
mention of the same. 

Steeu in 1900 reported a case of a woman aged thirty-tliree well advanced in. 
pregnancy who had a sore throat and nasal discharge. The next day she had a slight 
membrane on her right tonsil, no pyrexia, and no enlarged glands. Her pulse rate 
was accelerated and a bacteriologic examination showed the Klebs-Loeffler baciUus. 
She was given 1500 units of antitoxin and the next day delivered a full-term infant. 
When the child was four days old it developed difficult nasal breathing and the next 
day, membrane on its right tonsil. The child was given a total of 1350 units of 
antitoxin and recovered. 

E. Casavecchia in 1901 reported a case of a gravida ii, para ii, twenty-four years 
of age, who in the eighth month of pregnancy was suffering from diphtheritic 
laryngotracheal bronchitis. She was given Behring’s antidiphtheritic serum in 1000 
unit doses and after the fifth injection of serum, the patient delivered a living fetus 
weighing 2500 gm. The serum was repeated three times and the patient recovered. 



134 


ASIERICAN JOURNAL OF OBSTETRICS AND GITNECOLOGT 


D. E. Eanson in 1909 reported a case of a pregnant woman contracting dipiitlieria 
from her two children, having diphtheritic memhrano in her throat. Tlie woman was 
given 4000 units of antitoxin followed by 3000 in twelve hours. Ten hours after 
the second injection her child was born and took the breast, although her membrane 
and fever remained. The child did not contract the disease and the mother recovered. 

I am reporting a ease of laryngeal dipiitlieria complicating tlie puer- 
perium, this case being unusual in tliat for three days prior to delivery, 
the patient had a sore throat. There was no membrane visible at the 
time and after the dei'elopment of a clinical virulent laz’jmgeal diph- 
theria, there was still absence of membrane. This sore throat was not 
accompanied by any increased temperature or pulse rate and when the 
disease manifested itself clinically about thirty hours after deliver}*, a 
diagnosis was immediately made and heroic measures of therapy in- 
stituted hut without avail. 

Mrs. P. O’ll., aged forty-two, gravida vii, para vii. Pirst day of last menses 
March 24, 1931. Her past medical history is not significant except for pyorrhea 
alveolaris a year ago for which she had all her teeth removed. The patient’s mother 
died of heart disease in late adult life, and otherwise her family history is negative. 

During her present pregnancy she iiad occasional transitory headaches and at- 
tacks of dizziness and swelling of her feet and ankles. She had attacks of gas alter 
eating and was bothered by constipation. Her physical examination was essentially 
negative except for tenderness in the region of her gall bladder, and her blood pres- 
sure and urinary examinations were negative throughout her present pregnancy. 
On December 11, 1931, while making an antepartum visit to the patient’s home, 
she remarked that lior two sons, aged ciglit and ten respectively, wore suffering 
from tonsillitis which had abated hut had left them with “sore glands” in their 
necks. I looked at the boys but found notliing except some enlarged anterior cervical 
glands, both their throats being clear. The patient was warned at the time to take 
great care in not exposing iicrself to any acute infections as she was very close to 
term. 

The patient was admitted to the Montifiorc Hospital December 30, 1931, at 12 -.45 
A.M., stating she had had several labor pains. On examining her in the labor room 
she remarked that three days ago lier maid had a very sore throat and she helped 
out by doing her own housework. That same evening her throat became sore and 
had bothered her ever since. Examination of her throat revealed a slight injection 
of her pharynx on the left side. Abdominal and rectal examination, showed her 
to be in definite labor and the sore throat was forgotten. 

At 2:49 A.M., the patient delivered spontaneously vortex H.O.A., a male child 
weighing 3880 gm. There was a small first degree tear of the fonvehette. The 
expulsion of the placenta was Sohultze spontaneous and the bleeding was slight. 
The patient had sodium amytal grains "VT during the first stage of labor and ether 
for her perineal stage. She was returned to bed in good condition. 

About twelve hours after delivery the patient’s pulse, temperature, and respira- 
tions were normal. She was feeling fine except for her sore throat. Examination 
at this time showed some increased inflammation of the left tonsil with a small pus 
pocket. Her throat was painted with 10 per cent silver nitrate and a gargle 
prescribed. 

Early the following morning, December 31, 1931, at 12:30 a,m., the patient 
was awakened by her sore throat which kept her uncomfortable during the whole 
night. Toward daylight she began to have increased expectoration, difficulty in 
swallowing, loss of voice, not being able to talk above a whisper, some dyspnea and 



HERSH: LARYNGEAL DIPHTHERIA COMPLICATING PUEBPERITJM 135 


difficulty in bringing up thick tenacious mucus which choked her. She also com- 
plained of a sticking pain deep in her throat pointing to the region of the cricoid 
cartilage. At 12:40 P.M., her temperature was 102.8°, pulse 148, and respiration. 24, 
and Dr. Friedman of the Nose and Throat Department was called in to look at her 
larynx. The indirect laryngoscopic examination showed a swelling of the false 
cords and an entire absence of any false membrane either in the larynx or throat. 
We were greatly eoucerned about the possibility of a laryngeal diphtheria, therefore, 
a direct smear and culture were taken of the patient’s throat, and it was decided 
that if the smear were to be negative for the diphtheria bacillus we would still give 
the patient a large dose of antitoxin before waiting for the culture report. 

The laboratory examined the direct smear immediately and found B. diphtheriae 
in large numbers. The patient was immediately given 95000 units of diphtheria 
antitoxin intramuscularly, was removed from the obstetric floor and isolated. The 
patient was given 500 c.c. of 10 per cent glucose intravenously about one-half hour 
after the administration of the antitoxin. Since the newborn had been exposed to 
a seemingly virulent case of diphtheria, he was given a prophylactic dose of 1500 
units of antitoxin and also isolated. 

Toward evening the patient was becoming more toxic and breathing more dif- 
ficult. A second examination of the larynx showed such large amount of swelling of 
the false cords that a view of the true cords was entirely obliterated, and the presence 
of any false membrane not observed. Dr. J. S. Baird, the Director of the Municipal 
Contagious Hospital, was called in consultation, and at 10:15 p.M. he intubated 
the patient because of her marked respiratory difficulty. The intubation immediately 
relieved her dyspnea and improved her pallor, but she continued to expectorate a 
now blood stained mucus which was very annoying to her. Morphine and atropine 
sulphate were given in small repeated doses and the patient spent a very restful 
night. 

The next morning the patient’s condition was fair. She was taking liquids in 
teaspoonful doses and in order to give her more fluid to combat her toxicity 1000 
c.c. of 10 per cent glucose was started intravenously. Although the administration 
was not rapid after 840 c.c., it was stopped because of dyspnea and cyanosis. 

Late that afternoon the temperature began to drop, the pulse going up and becom- 
ing weak and thready. The patient did not respond to cardiac stimulants, the 
pallor increased and an acute pulmonary edema supervened. The heart continued 
to fail and the patient died at 9:00 p.M. The intubation tube was removed post- 
mortem and was found free of obstruction and with a small piece of membrane 
adhering to its lower pole, the first seen throughout the whole course of the 
disease. The membrane was cultured in the laboratory and gave a gro-wth of 
B. diphtheriae. 

COMMENT 

This case is presented in detail because it has many interesting 
features. I mentioned the sore throat in the patient’s two boys occur- 
ring nineteen days before her delivery, and the sore throat in her house- 
maid three days before delivery, as a possible etiologic factor. Her 
entme family were therefore immediately cultured, including the house- 
maid, but with negative results. There was no diphtheria in the 
neighborhood where the patient lived, and none of her friends or rela- 
tives had knovungly been exposed to the disease. Several friends who 
had visited the patient the night before the onset of the laryngeal symp- 
toms, submitted to culture as well as all the hospital personnel who had 
contact 'vntli the patient, with negative results. 



136 


AiMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


From the reports in the literature the infection of a mature adult 
woman in the puerperal state with laryngeal or pharyngeal diphtheria, 
is very rare. This is a chance infection, yet since it does occur, and with 
such tragic consequences as in this case, it should he kept in mind. 

The question of giving the newborn a prophylactic dose of diphtheria 
antitoxin was quickly decided upon, even though they are thought to 
inherit a transient congenital immunity. If there was a lack of this 
immunity in the mother, surely the chances of the infant inheriting 
such immunity would be obscure. In Steen’s ease the infant developed 
diphtheria when four da3's old, and G. Blechinaun and M, Chevallcy 
report two infants contracting the disease from an older infant who was 
not isolated. They believe that diphtheria is not observed under seven 
months of age because of relative isolation and not inherited immunity. 

Another clinical feature that cannot be overlooked in this case is the 
cardiac death. I 2Jrcviousl3' mentioned the patient’s histoiy of pyorrhea 
alveolaris and the presence of a mild chronic cholecj’-stitis. These 
coupled with seven pregnancies that in themselves deplete the cardiac 
reserve, offer enougli undermining of mjmeardium to make it unable to 
advantageouslj' withstand the virulent toxin of diphtheria. 

REFERENCES 

CasavcccJlia, E.: Gazz. de osp., Milano 22; 605-608, 1901. Hanson, J). E.: 
J. A. M. A. 52: 556, 1909. Steen, E. H.: Brit. M. J. 1: 575, 1900. Slander, 
Duncan, and Sisson: Am. J. OcsT. & Gynec. 2: 44-50, 1926. Bicchmann, G., and 
Chcvallci/, M.: Nourrisson 10: 44-50, 1922; abst. J. A. M. A. 78: 926, 1922. 

445 Union Trust Building. 


QUININE INSUFFLATION TREATMENT OF TRICHOMONAS 
VAGINALIS. PRELDIINARY REPORT 

Julius H. Sure, M.D., and Jasies E. Bercey, M.D., Milwaukee, Wis. 

(From the Department of Obstetrics and Gynecology, Mt. Sinai Hospital) 

T he fact that Trichomonas Amginitis is a clinical entity and of not in- 
frequent occurrence is not further disputed. Our reason for bring- 
ing the subject to attention again is onl.v that the manifold and various 
treatments have so far proved unsatisfaetoiy. The antiseptics, the dj’^es, 
lactic acid, and Lassar’s Paste have relieved maiy cases, cured a few, 
but the majority come back wth a reinfection or recurrence shortly 
after a menstrual period, or, if treatment is relinquished, after some 
lapse of time. 

It occurred to one of us (J. H. S.) that since the oi’ganism is a proto- 
zoon, and since quinine is an agent which frequentty destroys some of 
the protozoa, this cinchona alkaloid might be useful in the treatment of 
such cases. 

Case 1.— H. B. P., -n-as seen October 12, 1931, aged twenty-four, married, nullip- 
ara, complained of an irritating discharge for some length of time. Trichomonas 



SURE AND BERCEY: TRICHOMONAS VAGINALIS 


137 


four-plus positive. Tliis case was selected because the patient bad not been treated 
before. No cleansing, scrubbing, or antiseptics were nsed. 

The specimen recovered from tbe patient was studied under the microscope. A 
small quantity of quinine sulphate powder was mixed with water and allowed to 
trickle under the cover glass. Immediately the organisms were thrown into a spasm. 
Several minutes later, the motiUty and activity of the organisms were seen to di- 
minish and then stopped entirely after a short length of time. Long, narrow crystals, 
shaped like disorganized cordwood appeared under the mieroscope, which crystals we 
learned to recognize as those of quinine. 

Quinine sulphate powder, about fifteen grains, was blown into the vagina with a 
powder blower, and patient asked to report the following day. Next day, specimen 
taken from the same patient showed many quinine crystals and many dead (non- 
motile) trichomonads. 

Daily insufflations and study of slides showed less and less purulent discharge with 
disappearance of the trichomonads on the fourth day after the initial treatment. 

Patient was not seen for a week during which time she had a four-day menstrual 
flow. October 22, patient’s vagina was perfectly dry, with no discharge, no 
trichomonads found. After her December 6 menstrual period, slide showed no trich- 
omonads and no discharge. Last seen January 2, 1932, no discharge, no trichomonads, 
and patient dismissed. 

Case 2. — ^Mrs. E. W., aged twenty-five, was treated in clinic off and on from March 
28, 1927, to October 13, 1931, for neisserian infection. October 13, 1931, she still 
complained of an irritating vaginal discharge, at which time trichomonads were 
discovered. Quinine used as in Case 1, October 17, and October 24. October 31, 
no discharge; November 7, menstruating and quinine used during period, November 
14, no discharge and no trichomonads present; November 21, no burning, no itching, 
no vaginal discharge and no trichomonads. December 5, postmenstrual slide, no treat- 
ment, no discharge, no trichomonads. December 12, no trichomonads, no discharge, 
and no treatment. December 19, no trichomonads and no treatment. January 2, 
1932, no discharge, no treatment, and patient dismissed. 

Case 3. — ^E. S., aged forty-six, was first seen March, 8, 1930, for spotting after 
coitus, when polypoid endocervicitis was diagnosed. Treated by actual cautery. 

Eebruary 7, 1931, complained of burning discharge, and trichomonads found. 
Treated with soap scrub, bichloride douche. Treated at various times to September 
19, 1931, with various medicaments, without any improvement. October 3, 1931, 
Lassar’s Paste used. October 10, 1931, trichomonads still present. Quinine insuf- 
flation. October 17, 1931, no discharge for the first time in many months and no 
trichomonads. October 24, 1931, vagina dry, no discharge. Patient not^seen since. 

Case 4.— V. B., aged twenty-seven, first entered the out-patient department Oc- 
tober 29, 1928, for metrorrhagia and vaginal itching, dating back from a twin de'- 
livery in April 1928. The smears showed gram-positive and gram-negative bacilli 
with many pus cells. November 14, 1931, trichomonads discovered. Quinine insuf- 
flation as in preceding cases and 15 gr. capsules given patient, to be introduced in the 
vagina each night. November 21, no discharge, no trichomonads. Quinine insuf- 
flation. November 28, no discharge, no trichomonads. Quinine insufflation. De- 
cember 5, vagina clean, no discharge. Quinine insufflation. January 5, 1932, no 
discharge, no trichomonads. Patient dismissed. 

Case 5.— E. IV., aged twenty-four, first seen August 3, 1931, with leucorrhea, odor 
and burning. EndocervLx cauterized. November 17, 1931, trichomonads found. 
Quinine insufflation and capsules at home for one week. November 28, 1931, no trich- 
omonads. Quinine insufflation. December 19, 1931, postmenstrual slide showed no 
trichomonads and no discharge. Quinine insufflation. January 2 1932 no 

trichomonads. ’ ’ 


138 AJIKRICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 

Case C. — F. K., aged fifty, first admitted August 8, 1931, for vaginal itch, hurn- 
iiig. jMcnopauso twelve years ago. Slides showed trichoiiiouads four-plus and sugar 
in urine. Treated with sodium bicarbonate and sodium perborate. August 15, 1931, 
no improvement. September 18, 1931, instillation of 10 per cent nicrcurochrome 
daily, no improvement. November 7, 1931, no improvement, quinine used. November 
22, 1931, no discharge; itch stilt present. November 28, 1931, quinine insuHlation. 
No trichomonads found; itch still present. Urine still showed sugar and patient 
prcsentlj’ under care of medical department for diabetes niellitus. 

Case 7. — N. il., aged twenty-one, first seen November 17, 1931, complaining of 
discharge, burning and itching. Date of last menstrual period was November 16, 
1931. Claims to have had burning and itching for six months, and had been treated 
before by someone else with mcrcurochronie and vaginal tampons. Trichomonads 
four-plus. Quinine insufilation. November 19, 1931, nonmotile trichomonads. 

Quinine insufilation. November 20, 1931, trichomonads still present and nonmotile. 
November 21, 1931, no discharge and no trichomonads found. Patient has not re- 
ported since. 

COMMENT 

Wliile tlie number of cases is very small and no positive conclusion 
should be drawn from the treatment of these few instances of Trich- 
omonas vaginitis, still the results so far are so good that we have no hesi- 
tancy in inviting the medical profession to try it. 

CONCLUSIONS 

Seven cases of Trichomonas vaginitis were reported, six of the patients 
having received miscellaneous treatment with no improvement. All 
seven improved clinically and microscopically under the use of quinine 
treatment.* 

Goldsmith Building. 

•At present we have five additional cases under treatment with apparent 
equallj' g-ood results. 


BLOOD CHEMISTRY STUDIES OF NORJlIAL IIEWBORN 

INFANTS 

A Preliminary Communication 
I. Blood Sugar Estimations 

Albert W. Holman, M.D., and Albert JMathieu, M.D., Portland, Ore. 

T he results of our studies of the blood sugar levels in women suffer- 
ing from true toxemia® in the last trimester of pregnanes^' agreed 
with the findings of Titus.^ Prom this fact we were led to the premise 
that the offspring of these women must necessarily have a hypoglycemia 
and that hypoglycemia must often be the cause of neonatal death. We 
therefore began to give, empiincally, 5 to 6 gm. of glucose in 50 per cent 
solution to the babies of toxemic mothers, administering it by syringe 
into the umbilical vein. These babies seemed to do better and the mor- 


*We use this expression to differentiate from nephritis. 



HOMIAN ANP MATHIEU: BLOOD CHEMISTRY STUDIES OF INFANTS 139 

tality rate of twenty babies, born alive, of toxemic or eclamptic mothers 
was 5 per cent, the only one which died being a seven months’ child with 
a torn tentorium. 

Table 1 


mother’s blood 


baby’s blood (cord) 



2 


90 


3 

4 

5 

6 

7 

8 
9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 
21 
22 

23 

24 

25 

26 

27 

28 

29 

30 

31 

32 

33 

34 

35 

36 

37 

38 

39 

40 

41 

42 

43 

44 

45 

46 

47 

48 

49 

50 


121 

101 

101 

85 

105 

106 
91 
91 
74 

104 

140 

70 

114 
107 

76 
85 
• 80 
80 
80 
121 
72 
90 
129 
109 
SO 
104 

109 
80 

122 

115 
72 
85 
87 

112 

87 

114 

96 

78 

107 

110 
SO 

110 

140 

132 

80 

ICO 

90 

100 


j Twins 

80 '^ 

87 

93 

70 
101 
104 
112 

75 
80 

101 

129 

72 

76 
109 

63 

101 

60 

78 

81 

76 

60 

96 

96 

63 

68 

90 

116 

67 

107 

109 

71 
80 
70 

104 

74 

104 

74 

72 
87 

100 

70 

110 
126 
140 

80 

170 

100 

50 


102 average 


90.4 average 





140 AIMERICAN JOURNAL, OF OBSTETRICS AND GYNECOLOGY 

The next step seemed to be a quantitative estimation of the glucose in 
the blood of infants from toxemic mothers. Preliminary to this, how- 
ever, we undertook a comparative study of the glucose in the bloods 
of normal mothers and their babies, at delivery. 

TECHNIC 

Before the cord was cut, a needle was inserted into the umbilical vein several 
inches from the umbilicus and the blood withdr.awn and placed immediately into 
an oxalatcd tube.® In some instances, however, the blood was taken directly from 
the maternal end of the cord, after it had been cut. Simultaneously blood was 
drawn from the median basilic vein of the mother. The Ilaakins, Osgood modifi- 
cation of the Schaffer microcopper method of blood sugar estimation was used rou- 
tinely in all tests. No blood was allowed to stand more than two hours’ before the 
sodium tunstatc-sulphuric acid filtrate was made. 

It wiU be seen (Table I) that the blood sugar levels in this small series 
fall into the same general range as do adult levels. Also that in most 
instances, the babies’ blood sugar levels were relatively the same or 
below those of their mothers. This would indicate that if the mother 
suffers from hypoglycemia the fetus probably does. 

As Stander* points out, and as our work has confirmed, the toxemic 
mother has a lowered alkali reserve. Hence, it is reasonable to suppose 
that her fetus will also have a lowered alkali reserve. We are now study- 
ing the comparative alliali reserves of newborn babies and their mothers 
with relation to the blood sugar levels and will report our results later. 

CONCLUSIONS 

1. The majority of normal babies have blood sugar levels at birth 
relatively the same as, or below, those of their mothers. 

2. It would appear that babies of mothers with hypoglycemia must of 
necessity have a hj’poglyeemia in the majority of instances. 

3. The neonatal mortalitj^ of babies born of toxemic mothers can 
probably be decreased bj^ the administoation of glucose to these infants 
at birth. 

REFERENCES 

(1) Titus, Paul, Dodds, Pa\d, and Willetts, E. IF.: Am. J. Obst. & Gynec. 15: 
303, 1928. (2) Osgood, E. E., and EasUns, E. D.: Laboratory Diagnosis, 1931, 
P. Blakiston’s Son & Co., 284. (3) Nicholson, D.: Labor.atory Medicine, 1930, 
Lea and Pebiger, 136. (4) Stander, E. J., and Eastman, N. J.: Am. J. Obst. & 

Gynec. 20: 822, 1930. 

545 Medical Aets Building. 

415 Stevens Building. 



URETBRONEPHRECTOMY DURING EARLY PREGNANCY 

R, B. McKnight, M.D., P.A.O.S., and Reid Patteeson^ M.D., 
Chaedotte, N. C. 

T he surgeon is frequently called upon to operate during the course 
of a pregnancy. Most frequently the lesion demanding his attention 
is in the appendix, and next in order, the gall bladder, and then the thy- 
roid gland. These "will constitute over half of the operations of necessity 
during gestation. In the lesser group of cases wiR he found quite a varie- 
ty of intraabdominal and extraahdominal surgical lesions, for nLieh op- 
erations on the kidney constitute about 4 per cent of the "whole, and rough- 
ly 10 per cent of the lesser miscellaneous group. 

Schmidt= in 1915 collected 6 cases, 1 liis ow, in whicli nephrectomy had been per- 
formed during pregnancy, and in addition to Hartman’s collected series of 30 cases 
reported in 1913, made a study of the entire group. In this group there were 2 ma- 
ternal deaths, 3 spontaneous abortions, 1 induced abortion, 1 induced labor, and in 1 a 
dead fetus was extracted. Mussey and Crane^ of the Mayo Clinic in 1927 reported a 
series of 370 operations of necessity performed during pregnancy over a period of ten 
years. In this series there were only 4 maternal deaths and 17 miscarriages. (Inter- 
estingly enough all 4 deaths followed operations on the appendix or gall bladder, and 
over a third of the miscarriages followed operations on the uterus (myomectomy) 
or on the ovary.) There were 14 operations performed on the kidney, of which only 
2 were ureteronephrectomy. In this group there were no maternal deaths and only 
one miscarriage. They concluded that any operation can be performed prior to the 
fifth month of gestation without undue risk to the mother and child. 

CASE EEPOET 

We wish to report a case where ureteronephrectomy was performed dur- 
ing the first month of pregnanej’, without knowledge of the patient being 
pregnant. 

A young white girl, aged nineteen, who said she was single, was referred to one 
of us (Dr. McKnight) complaining of excruciating attacks of left-sided pain. Her 
fiunily history was of no importance. Menses began at twelve and had always been 
normal and regular. She stated that her last period was just over. Her past medi- 
cal history was negative except for the usual diseases of childhood, and these attacks 
of pain coming on at irregular intervals for the past two years. It seemed that they 
would .appear after fairly strenuous exercise such as dancing or vigorous walking. Two 
months before she was first seen she had a very severe attack of left-sided pain ex- 
tending from the renal area dorvnward and inward toward the bladder and vulva. 
Since then she has liad attacks every few days. The pain was evidently acute, as it 
caused her to cry out and writhe in bed and frequently required large doses of mor- 
phine for relief. She noticed no blood in the urine; although there was some urinary 
frequency but no pain on voiding. Dor the past week she had been confined to bed 
under morphine and symptomatic treatment, but suffering nevertheless. 

Examination revealed a well developed and nourished young white woman, weighing 
about 110 pounds. Her blood pressure was 100 systolic and 64 diastolic; pulse 100; 
temperature 99.0°. Examination was negative except for marked pain, tenderness, 
and rigidity over the left renal area extending domiward and forward over the abdo- 

141 



142 


AMERICAN JOURNAL OP OBSTETOICS AND GYNECOLOGY 


meu toward the bladder. Pelvic and rectal examination revealed no abnormality. Her 
urine contained a trace of albumin and many pus cells; hemoglobin was 70 per cent 
(S.ali]i); leucocytes 26,000; Wassermann negative and blood urea lo mg. per 100 c.c. 
of blood. 

She was taken to the hospital where cystoscopic examination and pyelogranis were 
made by Dr. J. P. Kennedy. The urine from the right kidney was normal^ and there 
was normal function; that from the left contained many pus cells, and this kidney 
showed about 50 per cent normal function. Pyelograms showed the right kidney per- 
fectly normal in size and position. The left ureter showed an obstruction about 20 cm. 



Fig. 1. — Ureteroneplirectomy during early pregnancy. 


above the vesic.ol orifice. Injection of opaque medium was followed by exposure and 
at the point of bifurcation this ureter showed two well formed pelvices m one cortex. 
It was considerably larger than the right. Left nephrectomy and ureterectomy was de- 
cided upon and was performed by Dr. McKnight. The ureters were dissected out to 
a point about 3 cm. below the bifurcation and there ligated and cut. The kidney was 
about twice the normal size and had many adhesions about it, but was freed with lit- 
tle difficulty and removed. The patient made an uneventful recovery and was dis- 
missed from the hospital the fifteenth postoperative d.ay with the wound draining a 
minute amount of serum. Pathologic report was double ureters and pelvices, pyelone 
phrosis, multiple abscesses in the parenchyma of the kidney. A catheterized urine 
specimen two months subsequently showed onty an occasional pus cell and was other- 
vrise normal. She had complete relief of her symptoms and had gained se^ era! poun s 
in weight. 


MCKNIGHT AND PATTERSON : tJKETERONEPHRECTOM‘2' 


143 


About four months after her operation she called for medical attention. On ques- 
tioning her she stated that she had no special trouble, but “just wanted to see the doc- 
tor as she had been married two months before operation and was a month pregnant 
when operated upon.” She stated that she had been married during a two- or three- 
day period when she was free from pain, and wanted to keep it a secret from her fam- 
ily. Examination revealed a five months’ pregnancy. She was referred to Dr. Eeid 
Patterson for obstetric care. 

Studies at this time showed an entirely normal urine, hemoglobin 60 • per cent 
(Sahli), 3,660,000 red blood cells, Wassermann negative and blood chemistry normal. 
Frequent urinalyses and blood pressure determinations showed that she had a normal 
period of gestation, toward the end of which the urine contained a little albumin and 
a few pus cells in a voided specimen. She entered labor at 7 :00 o’clock the morning 
of May 10, 1930, eight months after operation. External examination revealed irregu- 
lar uterine contractions, a breech presentation, and strong fetal heart sounds with a 
rate of 138. Vaginal examination at 10:30 a. m. revealed a rigid cervix, two finger 
dilatation, membranes intact, and a breech presentation. She was given 1/6 gr. of 
morphine sulphate and 1/200 gr. of hyoscine hydrobromide hypodermically to insure 
a comfortable first stage. She continued to make good progress and when the breech 
was well down on the perineum, a left episiotomy was done under ether anesthesia. At 
1:10 P. M. she delivered herself of a normal baby boy weighing 2920 gm. The episiot- 
omy was repaired in the usual manner and shortly afterwards the placenta was deliv- 
ered intact. There were only about 25 c.e. of blood lost in this delivery. Pituitrin 
and ergot were given postpartum. She reacted nicely and was removed to her room 
in good condition. Recovery was uneventful, and she was dismissed from the hospital 
the seventh day. At this time her red cell count was 4,480,000, hemoglobin 65 per cent 
(Sahli), and a catheterized specimen of urine showed fairly numerous pus cells and 
a cloud of albumin. One month later a voided specimen was entirely negative except 
for an occasional pus cell. Her health is now excellent, blood pressure, blood counts 
and urinalysis are normal. She has gained about 15 pounds in weight and has no 
complaints. 

COMMENT 

From a study of tlie scattered single case reports in the literature of 
nephrectomy dnring pregnancy, from the reports of Schmidt and of Mus- 
sey and Crane, and from observations on our own ease, it would seem 
that there is no cause for concern in doing renal surgery during early 
pregnancy, provided the remaining kidney is normal as to function and 
infection. Following operation in such a case, there is no reason why a 
patient should not continue through her period of gestation as though she 
had two perfectly functioning and normal kidneys. It is undoubtedly 
the better judgment to perform nephrectomy, rather than allow the preg- 
nancy to continue in the presence of a unilateral pyelonephrosis, with 
marked diminution of function, in a congenitally abnormal kidney. ' Such 
a condition would certainly augment the possibility of a severe bilateral 
renal infection before term. It is our belief that there are absolutely no 
grounds for therapeutic abortion in cases of unilateral renal disease, 
where, in a nonpregnant woman renal surgery would be indicated. 


REFERENCES 


Mwicy, R. D., and Crana, ,T. F.: Arch. Surg. 15: 729-736 1927 
Louis E.: Surg. Gyiiec. Ohst. 21: 679-684, 1915. ’ 

Professioxai, Buildikg. 


(2) Schmidt, 



HYPERTROPHY OP THE CLITORIS: REPORT OP TWO CASES 
Lyman W. jMason, M.D., DEN^^5:R, Colo. 

(From the Deparimeni of Obxtcfrics and Gynecology, University of Colorado School of 

Medicine) 

T he first case, and the one serving as the basis for this report, was a schoolgirl aged 
seventeen years; height 04 inches; weight 125 pounds. She was seen in the Out-Pa- 
tient Department of Gjmecology of the University of Colorado Medical School, to which 
she had been referred by the medical dcp.artment bcc.iuse of complaint of leueorrlioa and 
pain in the right lower quadrant. The pain had no rel.ation to her menstrual periods. 
Lcucorrhea began about two years ago, and had increased slightly in amount since. 

Past History . — Never any serious illnesses. Menstrual periods began at the age of, 
twelve; frequency every twenty-eight days; duration four days; moderate flow; never 
any dysmenorrhea. 

Patient’s mother and an aunt stated that the patient had always enjoyed excellent 
general health ; was robust ; had developed normally in every respect, but that she was 
unduly reticent, and that she accomplished her schoolwork with considerable difficulty. 

Family llisiory. — Father and mother living and well, aged forty-three and forty -two- 
respectively. One brother, nineteen, prob.abl}' tuberculous. Three sisters, ages eleven, 
fourteen, and sixteen, all in excellent health. Other family history negative, except for 
one uncle who is at present a patient in a psychopathic hospital, suffering from epilepti- 
form attacks, which ho insists arc duo to masturbation in j’outh. Psychiatric diagnosis 
is unknown. 

Physical Examination, — General examination entirely negative, e.xcept as noted be- 
low. Typical general feminine development and personality. Voice soft and pleasing. 
Normal hair development and distribution. Breasts well developed. 

Abdominal examination elicited marked tenderness over McBurney’s point, with 
some suggestion of rigidity of the right rectus. The pain complained of was attributed 
to occasional mild exacerbations of .a low-grade chronic appendicitis. 

External genitalia showed mature development. Hair growth abundant and of fem- 
inine distribution, except for a very thin, line of it reaching to the umbilicus. 

Labia majora normal. Labia minora were hypertrophied and redundant, hanging- 
from a markedly hypertrophied clitoris, which was rigidly erected. 

Vestibule negative. Urethral meatus normal. Hymen perforate and unruptured. 
There was a copious and constant secretion from the openings of both vestibular (Bar- 
tholin ’s) glands. Vagina negative. Cervix negative, except for a rather profuse secre- 
tion, entirely normal in appearance. No erosion. 

Uterus normal in size, in good position and freely movable. Both ovaries were pal- 
pated ; they were normally situated and were of normal shape and size. Tubes not felt. 
No pelvic abnormalities were found. 

The measurements of the erected clitoris were length, 5 cm., -width at the base, 
1.75 cm., and length of glans, 1.75 cm. 

Following the examination, the patient was questioned regarding any autoerotio- 
practices. These she at first flatly denied, but further indirect questioning elicited the 
fact that she had frequently and continuously masturbated, by stimulation of the cli- 
toris, beginning at the age of eight. She stated that about a year ago she stopped the- 
practice. This last statement, however, is probably not true. 

Chief interest in the case was directed to the clitoris, which apjieared as in Fig. 1- 
Before examination, and therefore before any stimulation of the genitalia, the cli- 
toris was rigidly erected. Only after some time at a subsequent examination did it be- 

144 



MASON: HYPERTROPHY OP CLITORIS 


145 


come flaccid, and then not entirely so. (Fig. 2.) The slightest touch anywhere about 
the external genitalia caused it to become rigidly erect, the erection occurring, as in 
case of a penis, by pulsations synchronous with the heart beat. Voluntary contraction 
of tho levator ani and perineal muscles increased its rigidity and direction of erection, 
also as in case of an erected penis. 

The clitoris was extremely sensitive. At one time while measuring its dimensions, 
orgasm occurred at the slight touch and pressure of the small celluloid scale used. This 
was entirely local in its manifestations, that is, marked by spasmodic contractions of the 
levators and perineal and vaginal muscles only. This lack of more general response I 
believe to be due to past frequent masturbation, which had accustomed the patient to 
the attendant sensations. 

Opportunity was subsequently afforded to examine this girl’s mother and her three 
sisters. The external genitalia in all were entirely within normal limits with the excep- 
tion of the oldest sister, aged sixteen, who presented a condition almost identical with 
the one reported here, with the exception that she had no complaint of leucorrhea, and 



Fiff. 1. Fig. 2. 


it was evident that the sensitivity of the organ was much less marked than in the case of 
her older sister. I am informed by a colleague, who has had under his care at various 
times two aunts and a female cousin of these girls, that there is nothing remarkable in 
the development of their clitori. 

There are various pathologic processes wliich cause enlargement of the 
clitoris. How’ever, in such cases as the one under consideration, presenting 
so marked a degree of ‘ ‘ normal ’ ’ hypertrophy, the condition is a congenital 
one, probably hereditary and probably a recessive characteristic. The 
mother stated that she had noticed that the clitori of these sisters were 
always larger than normal, men we consider that the clitoris is a homo- 
logue of the penis, with its muscular and erectile anatomy so similar, the 
wonder is not that marked hypertrophy sometimes occurs, but that it oc- 
curs so infrequently. 

Frequent and long continued clitoris masturbation (and almost all mas- 
turbation in the female is of the clitoris) usually causes some hypertrophy 
but never to any extent comparable with that seen in the present cases. The 



146 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


leueorrhea complained of is, I think, plij’^siologic for the conditions found, 
ivith the probably quite constant reflex stimulation of the cervical and ves- 
tibular glands. 

Conditions such as these bring up interesting problems in treatment. 
One is often in doubt as to the proper course to pursue, or the proper ad- 
vice to give. There is no doubt that a condition such as has been described 
is undesirable. However, it might be worse. It is necessary to take into 
consideration more than the small portion of anatomy involved. We must 
consider the individual in the light of her entire personality. This is true 
in all gsmecologie problems, and it is all too often ignored. 

Sex desire and gi'atification are largely a matter of the psyche, and we do 
little to increase our patients ’ physical and mental health by any procedure 
which removes the means for gratification but leaves the desire. These 
cases are more frequently than not proper ones for the consideration and 
treatment of the psychiatrist, or more happily the gjniecologist who is psy- 
chiatrist enough to Icnow when and how to treat the minds of his patients, 
and when to treat their genitalia. IMuch harm has been done in the past, 
and is still being done, bj'- such operations as circumcision, clitoridectomy, 
etc., for such indications as masturbation and other complaints which are 
dependent more upon mental factors than upon anatomical states. 

Dr. Franklin G. Ebaugh, of the Department of Psychiatry, saw and ex- 
amined this patient in consultation. His report in part follows : 

“Psj'cliiatric e.xaminntion revealed an average adolescent girl of the dull normal 
type. Her general reactions in the home, the school and the community appeared to be 
normal, and when closely questioned she did not show .any unusual or abnormal preoccu- 
pations regarding sex and the condition of the vulva. Her heterosexu.al interests .appear 
to be normal. She enjoys contacts with the opposite sex but has not been unduly erotic. 
Her interests are typically feminine and her physic.al development shows the usual sec- 
ondary sexual characteristics, with normal menstrual function, hair distribution, de- 
velopment of the breasts, etc. 

' ‘ Opinion on the basis of the above examination is that an operative procedure at the 
present time is not indicated and may actually do harm and lead to an emotional fixa- 
tion on the part of the child to the anatomical condition present. I am of the opinion 
that her sexual development and activities will be normal. Of course, later on in life, 
conditions of a physiologic or psychologic type may warrant an operative procedure. ’ ’ 

Appendectomy was advised, and the leueorrhea explained on a physio- 
logic basis. Since it was not marked^ profuse, no treatment was consid- 
ered advisable at the present. The condition of the clitori in both cases was 
minimized, and nothing was advised concerning it, tnisting that within a 
few years marriage will occur with establishment of normal heterosexual 
relations. 

These cases are reported because of the medical interest of a rather un- 
usual condition, and its occurrence in two members of one family ; to em- 
phasize the wisdom of considering such cases as much from a psychiatric as 
from a gynecologic standpoint, and to point out that ill-advised or hasty 
surgery is more likely to be harmful than beneficial. 

707 REPtmuc Building. 



CYANOSIS OP THE NEWBORN^' 

Case Reports Showng Value of X-Ray As An Aid In Diagnosis 
Edward H. Dennen, M.D., P .A.C.S., New \ ork, N. Y. 

R oentgen raj^s as an aid in diagnosis of cyanosis of the newborn 
should be used more frequently. Intracranial hemorrhage is often 
accepted as the most probable cause, but an x-ray picture may show that the 
trouble is in the chest. Thus the physician’s responsibility is lightened, 
and the risk of lumbar puncture is avoided. In making a differential diag- 
nosis, the simpler procedure should be used first as it may show that the 
other is not necessary. The presence of one of at least five other possible 





Fig. 1. 

conditions maj’- be established by the x-ray, and the treatment of each is 
quite different. Examples of these are shown in the following cases. 

Case 1. — Atelectasis; Mrs. E. W., aged twenty-tliree, para i, gravida ii, was ad- 
mitted to tliQ Doctors Hospital on May 21, 1931. After thirteen hours of labor, she was 
delivered by low forceps to an L.O.A., of a female child weighing 6 pounds and 15 
ounces. There was an initial asphyxia lasting fifteen minutes. During the next two 
hours the baby appeared normal. Then severe cyanotic attacks developed, occurring 
every ten or fifteen minutes. A physical examination did not reveal enough evidence on 
which to base a diagnosis. An x-ray of the chest (Pig. 1) taken when the baby was six 
hours old, showed nearly complete atelectasis of the left lung, and only partial expan- 
sion of the right lung. The cyanotic attacks continued for fifteen hours and then sud- 
denly ceased. During this time carbon dioxide and oxygen were given through the 
Henderson machine with each attack. 


icln*efDecember‘'22'\°3?''®’^"'^^ Gvnecological Section of the N. Y. Academy of Med- 


147 




148 


iVMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


A second x-ra}-, taken four daj’s later, showed normal expansion of both lungs. The 
baby was discharged well from the hospital on the fourteenth day, and is now seven 
months old. 

Case 2 . — Congenital Cardiac Lesion: Mrs. SI. C., para i, aged twenty-nine, was ad- 
mitted to the Harbor Hospital, April 25, 19.31. After seven hours of hard labor, she 
was delivered of a G pound boy by low forceps to an L.O.A. Tho baby was cyanotic for 
several hours after birth. There were several more attacks during the next three days, 
and cerebral hemorrhage w.as feared. Then for ten days the baby appeared well, but 
tho attacks returned and were much worse. 

The heart was found to be enlarged. This led to the suspected diagnosis of a con- 
genital heart condition. Tlie x-r.ay diagnosis was the same (Pig. 2). One week later 
the baby died, and on autopsy the diagnosis was confirmed. There were tliree chambers 
in the right heart; a rudimentary pulmonary arterj-, and a large patent foramen ovali. 



Fig. 2. Fig. 3. 

Case 3.~Pneumonia: Mrs. E. S., aged thirty-four, para v, was admitted to Bellevue 
Hospital, August 17, 1931. She had nineteen hours of hard labor with an L.O.P. posi- 
tion. After a tentative trial with forceps, delivery was accomplished by version and 
breech extraction, and Piper forceps to the after-coming head. The baby weighed 8 
pounds, and was markedly asphyxiated. The efforts at resuscitation were prolonged 
After using the Plagg and Drinker machines for an liour, the respirations were regular 
but labored. 

During the next day, there were several cyanotic attacks. On the second day, the at- 
tacks were much worse. An x-ray picture of the chest was taken, but before the repoit 
was returned, a lumbar puncture was done, and 13 c.c. of cle.ar spinal fluid, under mod- 
erately increased pressure were withdrawn. At this time, the diagnosis of severe intra- 
cranial injury, with extradural hemorrhage was considered probable. Later, the x-ray 
report showed consolidation of the upper lobe of the right lung, and a patchy consolida- 
tion around the right root (Pig. 3). Three days later the baby's condition was much 
improved, and on September 11, he was discharged in good condition. 

Case 4. — Thymus: Mrs. J. N., was admitted to the Polyclinic Hospital October 0, 
1931. She was a para ii, twenty-six years old, at term, but not in labor. Her first child 
was delivered by cesarean section, because of a generally contracted pelvis, with a breech 




DENNEN : CYANOSIS OP NEWBORN 


149 


presenting. The haby developed cyanotic attacks. The diagnosis .vas enlarged thymns. 
After x-ray therapy was given, the child recovered and is well today. 

At this time, a 6 pound 6 ounce baby was delivered by elective cesarean section. 
There was marked initial apnea. The baby was finally made to breathe with the aid o 
the Flagg machine, but the respirations were shallow. 

An x-ray picture showed an enlarged thymns. One x-ray treatment was given, but 
the baby died after seventeen hours. An autopsy was done. The brain was normal. 
There was a moderate amount of mucus in the air passages. The thymus was consider- 
ably smaller than its shadow appeared in the x-ray plate 14 hours earlier. The lungs 
showed early beginning pneumonia. The remainder of the autopsy was negative. 

Although the diagnosis was not substantiated by the autopsy, the case serves to 
illustrate one of the possible causes of cyanosis, and the method of diagnosing it. There 
was considerable hesitancy about presenting this case, first because of the pathologist ’s 



Pig. 4. Fig. 5. 


findings; and second, bec.ause of the discussion among authorities as to whether the 
thymus is really a pathologic entity in tliese cases. 

Case 5 . — Diaphragmatic Hernia: Mrs. M. S., para i, aged nineteen, a private pa- 
tient of Dr. Hawks, was admitted to the Polyclinic Hospital August 4, 1931, in labor 
at term. She was delivered after eleven and one-half hours of labor because of the dis- 
appearance of the fetal heart, by mid forceps to an E.O.A. The baby weighed 6% 
pounds and was in good condition. 

On the seventh day, the baby developed cyanotic attacks, with rapid and irregular 
respirations. The diagnosis of intracranial hemorrhage was accepted as most likely, 
and the condition was treated as such. The next day an x-ray of the chest was sug- 
gested, but the baby was considered too sick to be moved to the x-ray room. 

The responsibility for this condition was place upon the physician by the father of 
the cliild because of the forceps delivery. Later, an x-ray picture was taken which 
showed a left diaphr.agmatic hernia, with the intestines in the left chest (Pig. 4). As 
her condition was steadily getting worse, the baby was operated upon successfully on 
the thirteenth day by Dr. Coryllos. The postoperative x-ray showed normal lung expan- 
sion but the heart had not yet returned to the left chest (Pig. 5). The baby was dis- 
charged well after six weeks, and is now in good health at four months of age. 



150 AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 

All these cases of cyanosis in the delivery of which I had some part, oc- 
curred during a period of six months, showing to some extent the relative 
frequency of this condition. All were seen by consultants, and in only one 
was the correct diagnosis made before an x-ray picture was taken, showing 
the difficulty in making a diagnosis, and the value of x-ray aid. 

Intracranial hemorrhage was not the primaiy diagnosis in all, but in the 
absence of other evidence, it had to be considered as a possibility. Although 
an autopsy may reveal a condition which relieves the doctor of the respon- 
sibility of intracranial hemorrhage, it also shows, in some instances, that 
had an x-ray picture been taken, and the indicated treatment been given, 
death might have been prevented. If no autopsy is obtained, the real cause 
is often not known, but the weight of medical opinion may force the doctor 
to sign the death certificate as inti’aeranial hemorrhage. So both of these 
embarrassments may often be avoided by the early aid of a simple, flat 
x-ray picture of the chest, regardless of the bab}’- 's condition, or how sure 
one may be of his diagnosis. 

133 East Eightieth Street. 


RUPTURE OF A CORPUS LUTEUM AS A CAUSE OF ACUTE 
ABDOMINAL SYhlPTOMS^ 

Case Reports 

Waverly R. Payne, M.D., F.A.C.S., Newport News, Va. 

D uring tlio past two years I liave had occasion to operate on two instances of 
this condition, hoth being positively diagnosed by pathologists. 

Case 1. — E. B., aged twenty-three, colored, married five years but never pregnant, 
called me on January 5, 1030, because of severe abdominal pains. Her past history 
was negative. Her periods wore regular, every twenty-eight days, tlie last one ending 
one week previously. On several occasions she had had slight pains in tlie left lower 
quadrant, but never severe. On the occasion of the present attack during coitus she 
■was seized with a sharp agonizing pain in the left lower quadrant, wliich radiated 
across the entire lower abdomen. She became nauseated but did not vomit. There 
was no vaginal bleeding. Examination revealed a well developed, and well nourished 
young Negro woman writhing in pain. Her temperature ■was normal, pulse 100, heart 
and lungs negative. Tlie lower abdomen, especially on the left, was extremely tender 
and rigid. Morphine, % grain was given, and an additional % grain before relief 
was obtained. Vaginal examination ■was deferred until the following morning at 
which time the patient was much more comfortable. She was still extremely tender 
to pressure, and had marked rigidity in the left lower quadrant. The perineum was 
firm. There was no bleeding or unusual discharge. The cervix was smooth, and nor- 
mal in position. The uterus ■was slightly displaced, backward and to the right. The 
right ovary was palpable, and apparently normal in size. On the left there was marked 
tenderness in the region of the tube and ovary where a small soft mass was felt. 
Catheterized specimen of urine ■n'as negative. Wassermann negative. Hemoglobin 
77 per cent, R.B.C. 3,776,000, W.B.C. 6,600, polj's 51 per cent, small leucocytes 45 
per cent, large leucocytes 3 per cent, eosinophiles 1 per cent. The diagnosis of chronic 


Read at a meeting of 'Warwick County Jledical Society, January 14, 1932. 



PAYNE; RUPTURE OP CORPUS LUTEUM 


151 


salpingitis with left ovarian cyst was considered most logical. The cause of the acute 
pain was not satisfactorily explained. The patient was advised to go to the hospital at 
the time of the acute attack, but desired to Avait until the following morning. Ne.\t 
morning she Avas more comfortable, and her general condition better. Slie Avaited tAVO 
days longer before entering the liospital. During this latter interval there was no im- 
provement in her local condition. 

Operation: Under spinal anesthesia the abdomen Avas opened and about 200 c.e. 
of old blood Avas found in the pelvic cavity. Tlie right tube was chronically inflamed 
and adherent to the right ovary AA’hich was approximately normal in size. The left 
tube Avas chronically inflamed and adherent to the left OA'ary which was twice its normal 
size, and contained a large fresh corpus luteum body through which there Avas a rent 
1 cm. in length. The appendix Avas someivliat congested. Both tubes, the left ovary, 
and appendix were removed. 

Pathologic report (Dr. Sam Budd), was as folloAvs: Chronic salpingitis, chronic 
cystic ovaritis with a large fresh ruptured corpus luteum body shoiving on the surface. 
This patient had an uneventful conA'alescencc, and left the hospital on the tenth day. 

Case 2. — Miss M. V. E., aged thirty, clerk. On April 28, 1930, Avhile at work she 
Avas seized with a rather severe sharp pain across the loAver abdomen, Avhich Avithin a 
few hours became localized in the right lower quadrant. She Avas nauseated, and 
vomited once. Her past history revealed several attacks of tonsillitis, and several at- 
tacks of indigestion characterized by gas and belching. On several occasions she had 
noticed soreness in the region of the appendix. Her menstrual periods Avere usually 
regular every twenty-eight days, lasting flve days, accompanied by pain on the first day. , 
Her last period began three Aveeks previously. Physical examination revealed a nor- 
mally developed and Avell nourished young Avoman. Her tonsils Avere infected. Heart, 
lungs, etc., negative. Temperature 98.2, pulse 80, blood pressure 120/80. Examina- 
tion of the abdomen revealed marked tenderness, with rigidity over McBurnoy’s area, 
extending rather deep into the pelvis. Eectoabdominal examination revealed the 
uterus moderately displaced backward. There Avas marked tenderness in the right 
lower quadrant. A small soft tender mass Avas felt just posterior and to the right of 
the uterus. Urine was negative, Wassermann negative, hemoglobin 83 per cent, E.B.C, 
4,360,000, W.B.C. 8,400, polys 51 per cent, small leucocytes 46 per cent, eosinophiles 
2 per cent, basophiles 1 per cent. The preoperative diagnosis Avas appendicitis, and 
cyst of the right ovary. 


Operation : Under ether anesthesia a right rectus incision Avas made. The appendix 
was easily located. It Avas someAvhat longer than normal, and presenting in the pelvis. 
There were a feAV old adhesions, otherwise no demonstrable pathology. It Avas removed. 
The uterus was normal in size and in second degree retroversion. The left ovary and 
tube were normal. The right ovary Avas enlarged to three times its normal size, and 
presented numerous cysts on its surface, one of which had ruptured. There Avas ap- 
proximately 125 c.c. of blood in the culdesac. The right tube and ovary were removed. 

Pathologic report (Dr. Beecroft), was as follows: Appendix and right tube normal. 
The right ovary measured 3.5 by 2 by 2 cm. The surface presented a wrinlded ap- 
pearance. A small opening was noted at one end, and surrounding this the tissue was 
blood stained. The microscopic examination of this area shoAved a large corpus hemor- 
rhagicum developing in the margin of which luteal cells were seen. Eeeovery was un- 
eventful, and this patient left the hospital on the twelfth day. 


COMMENT 

In the two cases reported there was a sudden onset with definite evidence of intra- 
abdominal pathology. Neither of these cases exhibited significant changes in the 
blood picture. 

Medical Arts Building. 



ENTRANCE OF LIPIODOL INTO OVARIAN AND OTHER VEINS 

DURING UTEROGRAPHY 


John Charles Kilroe, B.A., M.D., and Alfred M. Helljian, 
B.A., M.D., F.A.C.S., New York^ N. Y. 

(From the First Gynecological Division Lennox Hill Hospital) 

B elieving that the condition presented hy the following case is still generally 
unknown, we herewith offer this report. No similar case report could be found 
in the literature up to 1932, and one of our largest clinics reported never to have 
scon such a case. 



Pig. 1. — Roentgenogram taken directly after Injection of lipiodol. 

Mrs. M. N., age thirty, was born in Italy and has been in the United States for 
ten years. She has been married six years; has never been pregnant. Her menses 
started at 13, are regular, of the twenty-eight day tj'pe, and last six to seven days; 
the bleeding is scanty and there is no pain. For four years the menses have been 
becoming less frequent and more scanty. She came to the Lenox Hill Hospital Clinic 
because of this reduction in her menses, her seeming sterility, and complaining of 
some indefinite pain on the right side of the abdomen, low down. 

Two examinations of the uterus and tubes by means of the injection of lipiodol 
into the uterine cavity demonstrated an apparent intravisation of lipiodol into the 
vessels of the uterine wall, and outlined both ovarian veins. This is easily seen from 
the accompanying pictures (Figs. 1 and 2). Bimanual examination is entirely neg- 

152 



KILROE AND HELLMAN : ENTRANCE OF LIPIODOL, 


153 


ative, and no direct cause for the phenomenon is demonstrable in this patient. This 
finding is most unusual. Eobin and Schapiro in the Neio England Journal of Medi- 
cine (Vol 205, p. 380) showed a picture of this condition which they produced by 
injecting lipiodol into the extirpated uterus, using great pressure. In our case on the 
living subject no undue pressure was used, and the process was not at all painful. 



Fig. 2. — Taken three minutes after injection of lipiodol. 


Three theories for the production of this phenomenon are mentioned: 

1. Injection under high pressure. 

2. Injection after injury of the mucous membrane of the uterine wall, as with 
a curette. 

3. Softening and permeability of the vessel walls. 

Neither of the first two reasons are applicable to our case, and no undue softening 
or permeability of the vessel walls could be demonstrated unless the phenomenon 
herewith described demonstrates that such permeability of the vessels exists. 

1114 Madison Avenue. 

44 East 78th Street. 




REPORT OF THE RESULTS AFTER TWELVE YEARS, IN A 
CASE OF URETEROVESICAL ANASTOi\IOSIS® 

H. Dawson Furniss, M.D., New York, N. Y. 

A l?., sixt}'-one years old, single. In August, 1919, "n-as operated upon for large 
• uterine fibroid. One iveek later developed incontinence of urine. 

When first seen by me on October 15, 1919, examination revealed a vesicovaginal 
fistula % inch in diameter, situated just to the left of the median line, % of an inch 



• Fig. 1. 

posterior to the interureteric ridge. The left ureter drained into the vagina through 
a minute orifice high in the left vaginal fornix. Indigocarmine was eliminated 
strongly from the left as well as from the right ureter. 

‘Presented at a meeting of the Section of Obstetrics and Gynecology , New York 
Academy of Medicine, February 23, 1932. 

154 


SCHOCHET AND LACKNER: PPANNENSTIEb INCISION 


155 


On October 30, 1919, 1 implanted the left ureter into the bladder according to the 
technic published by me in the American Journal of Ohstetrics and Diseases of Women 
and Children, 77: No. 1, 1918. On January 12, 1920, the vesicovaginal fistula -(vas 
closed through the vagina. The convalescence from both operations was uneventful. 

Since that time, except for hypertension, there has been no trouble. In September, 
1927, her blood pressure was 250/150, and has hept at this figure since. On cystos- 
copy the implanted ureter appears as a minute orifice, that will admit a No. 6 
catheter. Through it indigo carmine is eliminated as well as on the right, and in 
normal rhythm and force. On November 30, 1930, a pyeloureterogram was done. 
This shows only slight dilatation of the ureter, pelvis, and calyces. On January 27, 
1932, phenolsulphonephthalein was injected intravenously; in seventy minutes 33 per 
cent was eliminated. The urine was pus free. Only a few hyaline casts and a trace 
of albumin were found. 

Many of the ureterovesical anastomoses are followed by ureter stricture, hydro- 
ureter and hydronephrosis, often associated with infection. This successful outcome 
is reported as a stimulus to the performance of ureteral implantation in suitable cases. 

54 East Sixty-Second Street. 


AN INSTRUMENT TO OUTLINE THE PFANNENSTIEL 

INCISION 

Sydney S. Schochet, M.D., and Julius B. Lackner, M.D., 

Chicago, III. 

T he transverse or Pfaunenstiel incision offers an excellent exposure for pelvic 
operations, lessens the occurrence of postoperative hernias, and obviates the 
ugly scar appearance so frequently seen after the low median incision. 



It appears to us that the reason there are not a large number of adherents to 
the Pfaunenstiel incision in this country is due to the fact that it is frequently 
wrongly placed, and the curved transverse incision is not symmetrical with the re- 
sult, that a poor exposure is obtained. 

We have found that the apparent disadvantage of Pfaunenstiel incision can be 
obviated if the skin is marked before the operation. Eor this purpose we have de- 
vised a metallic marker with a curve, whose radius is 12.5 cm. with an arrow to 
indicate the median line and a transverse mark to indicate that the curve is bisected. 

The skin is marked with mercuroehrome along this curve just within the line of 
pubic hair. The classical incision is then made along this marked curve. 

55 East Washington Street. 



A CASE IN WHICH SEVERAL FOREIGN BODIES WERE FOUND 
IN THE VAGINA OF A FEEBLE-jMINDED 
PSEUDOHERMAPHRODITE^ 

Dn. R. A. Lifvendaul, Chicago, III. 

The liistorj’ avaihiblc was very inadequate because of the noucooperative atti- 
tude of this feeble-minded colored patient. Her only reason for coming. to the clinic 
of Dr. Emil Rics was the presence of a foul smelling discharge. No st.atemcnt was 
volunteered by her that any objects had been introduced by her until the vaginal 
examin.ation, and then with considerable difficulty. The only significant fact obtained 
was that she had never menstruated. 

The patient was short statured, colored, twenty-three years of age, with slightly 
prominent eyes but no other evidences of hyperthyroidism. The hair of the body 
had the typical male distribution and the chin was the site of a moderate growth of 
thin black short hair. The breasts were flat and of .a male type. The heart, lungs, and 
abdomen were free from any abnormalities. Her voice was of .a female tone. 

Vaginal examination revealed a normallj- developed \'ulva and introitus. The 
clitoris was 3 cm. long and up to 2 cm. in diameterj had a well developed glans, and 
prepuce of corresponding size. No pus was found in the urethra or labial glands. 
The vagina admitted the index finger with moderate ease and when the latter had 
been introduced to a depth of 5 cm., numerous small metallic bodies were palpated. By 
manipulation a hexagonal shaped nut 1 cm. in diameter was removed, with two round 
metallic beadliko structures like the buttons of a shoe. After this she became restless 
and refused further examination at this time. 

One week later she returned and at this time four more shoe buttons, two rubber 
balls, and the cap of a tooth paste tube were easily taken out with a small gall bladder 
scoop. A small cork, mth its broad end directed upwards was removed from granula- 
tion tissue in the posterior fornix. Noav she stated that all these objects had been 
inserted over a period of eight months. She denied lia^ang had intercourse at any 
time. 

Bimanual examination, after these foreign bodies had been removed, demonstrated 
a vagina of normal length but no cervix, body of uterus, or appendages could be 
identified. 


REPORT OF A CASE OF VELAMENTOUS INSERTION OF THE 
CORD WITH RUPTURE, AND SUBSEQUENT DEATH 
OP FETUS IN UTERUS! 

Dk. Henry B. Boley, Brooklyn, N. Y. 

S. K., white, aged twenty years, last menstrual period January 10, 1931, expected 
date of confinement, October 17, 1931. General physical examination negative, ex- 
cept for a systolic murmur at the apex. The uterus was in good position and 
enlarged to about a ten weeks ’ pregnancy. No bony abnormalities were noted. Blood 
pressure was 110/70. Urine was negative. 

Her prenatal course was uneventful except for occasional mild headaches, some 
pyrosis and slight edema of the legs. Blood pressure varied between 110 and 

•Described before meeting of the Chicago Gynecological Society, March IS, 1932. 

tPresented at meeting of the Brooklyn Gynecological Society, May 6, 1932. 

156 



DUNCAN-5IACL.ACHLAN : TELLOW ATROPHY OF LIVER 


157 


118 systolic except on one occasion -when it reached 130, but promptly returned to 
normal. Urine examinations -were repeatedly negative. Patient experienced quicken- 
ing on June 13. 

On October 13 at 3:30 a.m., the patient began having labor pains, mild and oc- 
curring about every twenty minutes. At 4:30 A.M., there was a large gush of water 
followed immediately by profuse bleeding and many large clots. She was then ad- 
mitted to the Jewish Hospital. At this time, she had only moderate vaginal bleed- 
ing and pains were slight and occurring every ten to fifteen minutes. Patient’s pulse 
and temperature were normal. She had good color and the blood pressure was 
140/90. The uterus was at full term, not tense, with fetus in E.O.A. position. 
The fetal heart could not be heard. The presenting part was floating and the cervix 
just admitted a tip of a finger. Voided urine specimen at this time was con- 
taminated with blood. A catheterized specimen was negative. It was felt at this 
time that death of the fetus and the hemorrhage was due to a rupture of a 
velamentous vessel. 

Pains ceased shortly after admission but a slight steady bleeding continued. 
Blood pressure at 2 p.m. was 150/100. On October 14 at 1 A.M., the pains started 
up again and from then on labor progressed normally and rapidly and resulted in 
a spontaneous delivery of a male stillborn at 9:50 a.m. The fetus weighed 6 pounds 
and the skull showed signs of beginning maceration. The placenta was then ex- 
pressed complete with membranes. No abnormal bleeding followed. The patient 
had an uneventful postpartum course. 

The placenta was 20 cm. in diameter. The cord -was inserted into the membranes 
about three inches from the placental margin; from this point, the vessel diverged 
in the membranes to the margins of the placenta. There was a rupture of one of 
the vessels at a point midway in its course to the margin of the placenta. 


EBPORT OF A CASE OP YELLOW ATROPHY OP THE LIVER IN 
THE LATTER PART OP PREGNANCY, WITH RECOVERY^' 

Hrs. Cameron Duncan and Glen R. MacLachlan, Brooklyn, N. Y. 

Mrs. N. B., colored, aged twenty-nine, was admitted to Kings County Hospital 
October 27, 1931. She had been seen one week previous in the prenatal clinic, and 
was advised then to enter the hospital at once for complete examination and ob- 
servation because of previous cesarean section. 

The past history was entirely negative. Tliere were two previous pregnancies, 
one ten years before, terminating in a forceps delivery followed by six weeks’ 
hospitalization, and one five years ago by cesarean section. The indications for both 
were not known. Menstruation normal, the last menstrual period Pebruary 12, 1931, 
the calculated date November 19, 1931. The pregnancy to date had been uneventful 
except for moderate nausea and vomiting during the first four months. 

There was present a slight thyroid enlargement and the abdomen was enlarged to 
the size of an eight and a half months’ pregnancy, with an upper midline scar from 
the previous cesarean section. Weight 155 pounds, height five feet, normal blood 
pressure and pelvic measurements. The laboratory data on admission, including 
urinalyisis, blood count and blood chemistry, was normal. 

On October 31, four days after admission, the patient was taken ill, first with chills 
then nausea, vomiting, headache, a rise in temperature to 102° and pulse to 12o[ 
Physical examination negative except for moderate injection of the pharynx and a 

‘Presented at meeting of the Brooklyn Gynecological Society, May G, 1932. 



158 


AMERICAN JOURNAL OF OBS'I’ETRICS AND GENECOLOGY 


mild nasal catarrh. A diagnosis of grippe was made. The urine at this time 
showed 2-plus albumin; otherwise neg.ativc. Blood count: 4,096,000 red blood cells, 
15,300 white blood cells, SO per cent hemoglobin .and 75 per cent polynuclear cells. 
A blood chemistry showed urea 35, creatinin 1.3, sugar 114. The foUon-ing day 
the patient appeared acutely ill, had a fainting spell and the temperature reached 
101°, with the pulse 12S and weak. At this time cardiac stimulation was commenced. 

On November 2, slight jaundice appeared for the first time. She complained of 
severe hcadacho and pain in the chest and back. She was still nauseated and not 
retaining food or fluids. At this time, tenderness below the right costal arch de- 
veloped. A surgic.al consult.ation on this date was negative for gall bladder disease 
or appendicitis. For the first time, casts ajjpeared in the urine, the albumin was 
increased but the blood count remained as on previous examination. The urine 
was neg.ativc for leucin .and fyrosin crystals. Tlie following da}-, November 3, the 
patient was still more deeply jaundiced, the severe headache, nausea and vomiting 
persisted, and she complained of generalized muscular aches and pains. A blood 
count on this date showed 3,500,000 red blood cells, 8,600 white blood cells, 75 
per cent hemoglobin and 75 per cent poljaiticlear cells. The coagulation time w.as 
six minutes. The icteric index was 78 and the Vanderberg test showed a direct im- 
medi.ate positive reaction. The upper liver margin was at the third rib, and the 
lower border three fingers below the costal margin. Opinion, toxic hepatitis. The 
fet.al heart had been he.ard and appeared normal up to this time, but dis.appeared 
November 4. 

On the afternoon of November 5, the patient went into labor and had an easy, 
spontaneous delivery of .a seven-pound macerated fetus. Nitrous oxide was given 
for five minutes. The next day, the p.aticnt was symptomatically improved. The 
increased liver dullness proviousl}' noted was lessened. The spleen was not palpable. 
The blood pressure was normal, as was the urine except for .a faint trace of albumin. 
The blood chemistry showed ure.a 168, creatinin 2, sugar 145. Bed blood cells 
2,350,000; hemoglobin 25 per cent; white blood cells 30,000; polynuclears 06; 
lymphocytes 30; monocytes 3; eosinophils 1; degencr.ative index 89 per cent; micro- 
cytosis two-plus; macrocj’tes one-plus; anisocytosis three-plus; reticulated cells 2 
per cent. On November 6, there was pronounced weakness and muscular pains. The 
jaundice remained but the liver was progressively getting smaller. A blood chemis- 
try at this time showed urea 158, creatinin 3, sugar 133, icteric index 113, Vander- 
berg direct immediate positive reaction. On November 8, the patient was clear 
mentally in contrast to her previous persistently apathetic state but the intake of 
food still caused vomiting. Tlie jaundice was definitely less and the blood chemistry 
practically the same as previously reported. On November 9, a 400 c.c. blood trans- 
fusion was given. 

The condition gradually improved but a second transfusion of 500 c.c. was given. 
The urine report was still negative for leucin and tyrosin. A third tr.ansfusion of 
500 c.c. was given on November 16. On this date, there were 2,500,000 red blood 
cells; 9,700 white blood cells, 65 per cent hemoglobin, and 73 per cent polynuclear 
coUs. From this time on, the patient made rapid recovery, had no subjective com- 
plaints and on November 23 ■was allowed out of bed. On November 25, twenty-six 
days after the onset of the illness, she was discharged in good condition. Treatment 
had included cardiac stimulation intermittently as indications arose, and repeated 
clyses of saline, and infusions of glucose, saline, and calcium gluconate, as well as 
the three blood transfusions previously mentioned. 

A blood culture taken during the period of acute illness was sterile. At the time 
of discharge from the hospital her blood count showed 4,000,000 red blood cells and 
70 per cent hemoglobin and a normal urinalysis and blood chemistry. The diagnosis 
was "acute hepatitis with partial acute yellow atrophy.” 



I>T3NCA^5-MACLACH1.M^ : Y3St.tjOVr ATROPHY OP HWER 


159 


DISCUSSION 

DE. SAMUEL A. WOLFE.— Cases of yellow atrophy of the liver are known to 
recover after persuing a mild subacute course. Mallory of Boston has reported a 
series of this type, clinically simulating catarrhal jaundice. Eegener.ation and fibrosis 
occurs, and the liver ultimately assumes the gross characteristics of typical Laennee’s 
cirrhosis. 

In the case reported, the diagnosis of acute yellow atrophy requires further con- 
firmation. The abrupt onset with chill and high temperature is rather atypical. 
The sudden hemolysis shown by a rapid drop in the number of the red blood cor- 
puscles and in hemoglobin are indicative of a hemolytic anemia. The overloading 
of the circulation with hemoglobin derivatives easily account for the enlargement of 
the liver reported early in the disease. The blood chemistry in both hemolytic 
jaundice and acute yellow atrophy are somewhat similar. Eetention of urea, uric 
acid, and creatinin, occurs in both. 

The Van den Bergh reaction and the icteric index as reported appear in hemo- 
lytic jaundice. The high icteric index is indicative of obstruction of the biliary 
radicles due to overload of pigment. In the light of these facts the diagnosis of 
acute yellow atrophy does not appear completely substantiated. 

DE. CAMEEON DUNCAN. — The fact that leucin and tyrosin crystals were not 
found is not a constant factor in acute yellow atrophy, as Hunter, in an analysis 
of 23 oases found 9 that had neither leucin nor tyrosin, 10 cases with both leucin 
and tyrosin, 3 cases that had tyrosin alone, and one case with leucin alone. 


Kottlors; The Treatment of Postoperative Urinary Eetention. Zentralbl. f. Gynak. 

54: 2530, 1930. 

Most of the commonly employed drugs such as urotropin, pilocarpin, calcium 
acetate, ammonium chloride, etc., do not have a direct influence on urinary reten- 
tion, but derive their efEect from psychic action. Obviously retention is due to 
one of two causes; muscle deficiency, or sphincter spasm. A postoperative patient 
is anxious to spare her abdominal muscle and, therefore, will not try to micturate. 
In this group, the personality of the physician is an important item. Sphincter 
spasm has been treated with antispasmodic drugs of the atropine group without 
much success. The writer claims that a rectal infusion of 50 c.c. of 2 per cent 
novocaine solution will be effective within one hour in the large majority of cases. 
Of 31 postoperative patients 84 per cent responded well to this therapy, urinating 
within an hour following the application. Even cases of urinary retention fol- 
lowing radical Wertheira operation were favorably influenced. 

Wn.LiAM F. Mengekt. 


Errata 

On page 939 of the December issue the word Standard’s in the twenty-first line from 
the bottom of the page should read Stander’s. 

On page 899 of the December issue, the second paragraph should read: 

It is therefore evident that the theory of an increase of CO. as a cause of slowing of 
the fctcil liGtirt sliould. 1)6 disCtird.6d ^instead of discovGrGd) 



Society Transactions 


NEW YORK OBSTETRICAL SOCIETY 
jMeetikg op jMarch 8, 1932 
The following papers were presented: 

Epithelial Kegeneration in the trtcrinc Glands and on the Surface of the tTterus. 
Dr. G. N. Papanicolaou. (See page 30.) 

An Analysis of the Menstrual Changes In Tuhcrculous Women. Dr. E. M. Jame- 
son. (See page 


BROOKLYN GYNECOLOGICAL SOCIETY 
jMeeting of May C, 1932 

The following papers were presented: 

Report of a Case of Velamentous Insertion of the Cord With Rupture, and Subse- 
quent Death of Fetus in Dtenis. Dr. II. B. Bolcy. (Sec page 15C.) 

Report of a Case of Yellow Atrophy of the Liver in the Latter Part of Pregnancy, 
With Recovery. Drs. C. Duncan and G. K. MacLaclilan. (See page 157.) 

Congenital Pneximonla of the Stillborn and the Newborn. Dr. J. Kaldor. (See 
page 113.) 

The Complications of Radiimi Therapy in Gynecology. Dr. G. G. Ward. (See 
page 1.) 


CHICAGO GYNECOLOGICAL SOCIETY 
Meeting of PebrujVRY 19, 1932 

The following papers were presented; 

The Technic of Radiation Therapy in Dterine Carcinomas. Dr. H. Schmitz. (See 
page 10.) 

Internal Rotation of the Petal Head, From the Viewpoint of Comparative Ob- 
stetrics. Dr. L. Rudolph and Dr. A. C. Ivy. (See page 74.) 


CHICAGO GYNECOLOGICAL SOCIETY 
D'Ieeting of March 18, 1932 

The following papers were presented: 

A Case in Which Several Foreign Bodies Were Found in the Vagina of a Feeble- 
Minded Pseudohermaphrodite. Dr. R. A. Lifvcndahl. (See page 156.) 

Report of a Case of Ovarian Embryoma. Dr. P. J. Sarnia. (See page 51.) 

Some tTrologic Complications in the Female. Dr. G. Rolischer. (See page 12S.) 

160 



Department of Reviews and Abstracts 

Conducted by Hugo Ehrenfest, M.D., Associate Editor 


Selected Abstracts 


Endometrium 

Hoftaiier, J,; Concerning the Etiology of Hyperplasia of the Endometrium, Surg. 
Gynec. Obst. 52: 222, 1931. 

The etiology of hyperplasia of the endometrium presents a problem which is still 
inadequately understood. Several writers have recently expressed the view that in 
ail probability an unrecognized endocrine factor is concerned in the etiology of this 
condition, i. e., in view of the present knowledge of the nature of hormones in the blood 
and in the urine, great caution siiould be exercised in drawing conclusions from positive 
or negative findings in them. 

Hyperplasia may reasonably be regarded as the manifestation of an overactivity of 
the anterior pituitary lobe. This conclusion, that an outside factor represents the 
primary cause of the disease, was reached when guinea pigs whicl) were treated par- 
enterally with derivatives of the anterior pituitary, produced conditions in the uterine 
mucosa, as well as in the ovaries, which were practically identical with those observed 
m endometrial hyperplasia in women. This obtained so long as the ovaries were pre- 
served but when they had been removed, the process was limited to the basal portion 
of the endometrium. This conclusion is corroborated by the clinical e.xperienee that 
tlie condition commonly recurs after repeated curettage. 

The question arises as to whether the anterior lobe of the pituitary registers its 
effect on the uterine mucosa directly or through the agency of the ovary. The author's 
observations indicate that the internal secretion of the ovary is essential for the 
cianges occurring in the upper part of the uterine mucosa— "the function.alis, ” while 
the basal layer is under the control of the anterior pituitary lobe, as iudged by the 

^Vm. C. Henske. 

'”r““ 's r. 

hv., “! !”'r, “■> tta 

lestetion, Wlueli 11. variou, l.m.oe, prito. « ““ '““"Sie na»i- 

0» L ...lies ZVZmTZ LT" T 'will, from „U.,, UU. 

riild from tie., cj-si, «... «J»t 

...aomoW. ,r.m a,.,. „„ > rrilh Ltta ft."; "*■ 

It was found that both estrin and +l,o -,7 ^ ^ ^ ® human uteri, 

characteristic reaction on the endometrium^"^ hormone produce a definite and 


161 




162 


AMERICAN JOURNAL OF OUSa-ETRICS AND GYNECOLOGY 


It is possible in cases in which mixed elTeets are obtained to determine by means 
of histologic study which of the hormones is predominant. 

The histologic appearances of the endometrium obtained from cases of Swiss cheese 
hyperplasia arc verj' similar to those found in animals which have been injected with 
extracts of placenta. 

Material obtained from the follicle cysts of human cases of hj-perplasia when in- 
jected into mice and rats, produced cstrus. The changes in the uterus of each case 
were similar in many respects to tho.se found in the uterus of the c.xperimental animals 
receiving the fluid from that case. Wm. C. Henske. 

Adler, K.: The Clinical Manifestations of Glandular Hyperplasia of the Endo- 
metrium, Monatschr. f. Goburtsh. u. Gyniik. 90: 340, 1932. 

The etiology of granular hyperplasia of the endometrium is not clear. In most 
cases, there arc enlarged ovaries with one or more follicle cysts and in the majority of 
cases, no corpus luteum is present. Adler studied C7 cases of endometrial hyperplasia 
from the clinical point of view. Most of the patients were more than thirtj'-six years 
of ago (68.7 per cent). The next most frequent group was between fifteen and twenty- 
five years. The most prominent symptom was uterine bleeding and this varied con- 
siderably in tj’pe. In the majority of cases the bleeding consisted of an increased flow 
during the menses but the intervals between the periods were prolonged. In most cases 
the uterus was enlarged and this was observed in the very young patients as well as 
in the older ones. Almost all of the patients were nulliparas. The uterus was generally 
softened and the cervical canal olTercd no resistance to mechanical dilatation. During 
the preclimactcric period and the menopause, the enlarged uterus was usually associ- 
ated with fibroids. The latter showed a special tendency to increased growth during 
the menopause. Zondek has shouai that at the onset of the menopause there is an in- 
creased amount of folliculin in the blood and urine. It is therefore conceiv.able that 
the h 3 ’porplasia in the climacteric maj’ be due to an excess of the proliferation hormone. 

During the reproductive years there is a special tendency toward hyperplasia among 
nulliparas; for of the 17 women between fifteen and thirty-five years of age, 14 had 
never borne children. On the other hand, among the 45 women who had hj-perplasia 
during the preclimactcric and the climacteric only 5 were nullip.aras. 

The treatment for women over fortj' j'ears of age is simple. After curettement is 
performed and the diagnosis made, roentgen-ray therapy should be employed. In 
women past the menopause curettage atone usually suffices. In j'oung women, a curette- 
mont is ncccssarj' for a diagnosis and it generallj' produces a temporary cure. How- 
ever, the condition usuall,y recurs. Hj’stercctomy is never necessarj’. 

J. P. Greenhill. 

Reinhart, H. L., and Moore, R. A: Tuberculous Endometritis, J. Lab. & Clin. Med. 

14: 413, 1929. 

The incidence of tuberculosis of the uterus is not as common as is often assumed. 
Primary tuberculosis of the female genital tract is extremelj’ rare, in fact the exact 
modus operandi of infection has never been proved. Most tuberculous infections of 
the genital tract are secondary. Infection is usually transmitted through the blood 
stream (metastatic) and the original lesion is most frequentlj’ in the lung or bronchial 
lymph nodes. Metastatic Ij^mphatic infection to the genitals is rare. The uterus being 
an organ which is constantly contracting, the Ij-mph flow through that organ is so 
active that bacilli are not permitted to remain in one place long enough to develop a 
lesion. With menstruation the uterus performs a “physiologic curettage” by shed- 
ding itself. This phj-siologic function together wdth the menstrual congestion pre- 
vents chronic infection with ordinarj- bacteria, and this same factor is probably opera- 
tive in the case of tuberculosis. 



ABSTKACTS 


163 


Eeinhart and Moore state that the maeroscopie appearance of tuberculous tubes 
and uteri in 75 per cent of cases cannot be distinguished from infectious lesions due 
to other organisms. Clinically, there is no pathognomonic symptom of tuberculous 
infection of the genital tract. The authors report two cases, worthy of note, the one 
with secondary tuberculosis of uterus and tubes, secondary probably to pulmonary 
tuberculosis, and the second a tuberculosis superimposed upon an atrophic fibrosis uteri. 
The authors conclude that there is a marked variation in the reported frequency of 
tuberculous lesions in the female genital tract; that the physiologic activities of various 
portions of the female genital tract may be responsible for variation in resistanee to 
tuberculous infection and that tuberculosis of the uterus is more frequently super- 
imposed upon a pathologic than a normal organ. W. B. Seebin. 


Miscellaneous 

Nakawaga, J.: Prolapse of the trtenis and Constitution. Japanese J. Obst. & 
Gynec. 14: 106, 1931. 

At the Gynecological Institute of the Kyoto Imperial University prolapse of 
the uterus was observed during the last nine years in 1.18 per cent of all the 
patients and prolapse of both the uterus and vagina in 2.57 per cent. More cases 
were found in young women than is generally believed. Parity played a role in 
the following order of frequency: quadripara, primipara, tertipara, sextipara and 
quintipara. There was a relatively large number of prolapses among multiparas 
because the incidence among them was 4.55 per cent. An asthenic constitution 
was observed in 34.1 per cent of the cases, and tuberculosis was noted in 36.4 per 
cent. The author believes that prolapse of the uterus is caused by an abnormal 
constitution and that there is a close relationship between prolapse and tubercu- 
losis. The latter leads to a deterioration of the constitution. 

J. P. GREENHlLTi. 


Wislocki and Snyder; On the Experimental Production of Superfetation. Bull. 

Johns Hopkins Hosp. 49: 103, 1931. 

On June 12 a healthy, mature female rabbit was mated at 4:50 p.m. On June 
16 at 12:15 f.m. this animal received 8 c.e. of anterior lobe extract intravenously. 
On the same day, at 4:30 p.m. they inseminated the animal ai-tificially. On June 17, 
at 9:15 p.m., the animal was killed and autopsied. 

The observation recorded demonstrated the possibility of successfully fertilizing 
a second set of ova. The living blastocysts had not prevented a second set of ova 
from becoming fertilized. Nor had the changes occurring supposedly in ovaries, 
tubes and uterus, after fertilization of the first set, prevented a second set of normal 
ova from being discharged and becoming fertilized. Tlie present experiment fails to 
support the concept of the primacy of the ovum. The ova do not apparently exert 
an inhibitory influence upon ovulation, fertilization and maturation of a second set 
of ova. 

This demonstration of the possibility of superfetation opens a number of avenues 
of investigation. It will be interesting to determine the fate of the second set of 
fertilized ova in the presence of the initial set of blastocysts. Will the period 
of transit through the tubes become altered? Will the spacing of the first set 
of ova or the reaction of the endometrium following their implantation prevent 
successful implantation of the second set? Does the time of implantation of the 
ovum depend upon the stage of development of the ovum or upon the condition 
of the endometnum? These and other questions can be answered by further 

C. O. Maland. 



Items 


AMERICAN BOARD OF OBSTETRICS AND GYNECOLOGY 

At the meeting of the Aincricun Association of Obstetricians, Gynecologists and 
Abdominal Surgeons hold at French Lick Springs on September 12, 1932, a resolu- 
tion was passed, taking note of the “increasing necessity for the determination and 
certification of specialists in the various branches of medicine,’’ to the effect that 
in the future candidates for Fellowship in this Association who profess to be spe- 
cialists in obstetrics and/or gynecology be required to be Diploniatcs of the Amer- 
ican Board of Obstetrics and Gynecology. Official action of the Executive Council 
is necessary for any special exceptions to this regulation. 


At the recent meeting and examination of the American Board of Obstetrics and 
Gynecology held in Los Angeles, December 7th, the following applicants wore approved 
for certification: 


Ma.x J. Abramson, Lo.s Angeles, Calif. 
Theodore W. Adams, Portland, Oregon. 

T. Floyd Bell, San Francisco, Calif. 
Warren Watson Bell, Seattle, Wash. 

R. Glenn Craig, San Francisco, Calif. 

Roy B. Fallas, Los Angeles, Calif. 
Frederic Pluhmann, San Francisco, Calif. 
George B. Grccnb.aum, Los Angeles, Calif. 
John Curtis Irwin, Los Angeles, Calif. 

O. Donovan Johnson, Los Angeles, Calif. 
Emil .T. Krahulik, Los Angelos, C.alif. 
Fred Lindcnberg, Los Angeles, Calif. 
Frederic M. Loomis, Oakland, Calif. 
Clarence W. Page, Berkeley, Calif. 

Tliree additional candidates were eo 
certification. 


Albert V. Pettit, San Francisco, Calif. 
Henry Rooney, Los Angeles, Calif. 
Moses II. Ross, Los Angeles, .Calif. 
Charles S. Salisbury, Los Angeles, C.alif. 
Henry IST. Shaw, Los Angeles, Calif. 

.Tohn W. Sherrick, Oakland, Calif. 

Alson A. Sliufelt, San Jose, Calif. 
Gordon Graliame Thompson, Seattle, 
Wash. 

William B. Thompson, Los Angeles, 
Calif. 

Leon J. Tiber, Los Angeles, Calif. 

Albert M. Tollmcr, San Francisco, Calif. 
John Vruwink, Los Angeles, Calif. 

itioned and four candidates failed of 


The next written examination and review of case histories will be held in cities 
throughout this country and Canada, wliere there are Diplomates who may be empow- 
ered to conduct the examination, on Ajiril 1, 1933. 

The next general, clinical examination is to be held in Milwaukee on Tuesday, June 
13, 1933, immediately preceding tlie annual session of the American Medical Associa- 
tion. Reduced railroad rates will apply. 

Earlj' application is requested from those desiring to qualify for these examinations. 
For further information and application blanks address Dr. Paul Titus, 1015 Highland 
Building, Pittsburgh, Pennsylvania. 


164 



American Journal of 
Obstetrics and Gynecology 

VoL. XXV St. Louis, February, 1933 No. 2 


Original Communications 


THE QUALIFICATIONS O^HE SPECIAL ^- 
President’s Address 

"Wauter T. Dannbeutheb, M.D., New York, N. Y. 

A political philosopher once made the epigrammatic comment that 
some men think that they have been called when they have not even 
been whispered to. One year ago, I was called to serve as yonr President 
without having been whispered to beforehand, and although anxious to 
avoid any bromidie remarks, I cannot refrain from expressing my grati- 
tude to you for conferring upon me the greatest honor Avithin your gift, 
and for affording me the opportunity to serve the American Association of 
Obstetricians, Gynecologists, and Abdominal Surgeons in a capacity I had 
never anticipated. 

Since the preliminary plans which culminated in the creation of the 
American Board of Obstetrics and Gynecology were proposed and formu- 
lated within this Association, and the parent bodies are responsible not 
only for having endorsed and supported the project since its inception, but 
also in part for its proper functioning, it seemed that at this time I might 
with propriety discuss some of the details involved in the operation of the 
new organization you have fostered. 

During recent years the medical profession has been afflicted with num- 
berless irresponsible self-styled specialists. Their rapid multiplication 
has been due to several factors, not the least of which is that the public be- 
gan asking who is a specialist before it thought to inquire what a special- 
ist is. In view of the fact that the emoluments of an expert in one of the 
special fields of medicine are greater than those of a general practitioner, 

*R^cl at the Forty-Fifth Annual Meeting of the American Association of Obstetrl- 
cians. Gynecologists, and Abdominal Surgeons, French Lick Springs, Indiana, September 


Nora: The Editor accepts no responsibility for the views and statements of authors 
US publisued in tlioir Original Communications.’^ 

105 


IG6 AMEUICAX .TOUKNAIi OF OH.STETRICS AKD GVXECOLOGY 

that a license to practice imposes no restrictions upon its holder, that the 
reprehensible secret division of fees will insure a satisfactory financial re- 
turn in many communities, and that the laity has had no criteria whereby 
it could distinguish those specialists who are well qualified from those who 
are not. it is not snrprisiii'r that certain men without the neccssaiy baelc- 
"round of intensive trainiufr and wide experience have been tempted to 
misrepresent themselves. Asepsis, the skillful administration' of anes- 
thetics, and modern operatinjr room technic have eliminated the hazards 
of pelvic and obstetric suiycry to sneh an extent that the lure of the oper- 
ating amphitheater is hard to resist. The pernicious tendency to teach 
senior medical students and hospital internes the refinements of major 
I)rocedures at the ex'pense of fundamentals is largely rcspon.sible for much 
of the un.iustifiablc and premature .specialization. Entirelj' too many of 
the recent graduates gain the impre.ssion that gyneeology and pelvic sur- 
gery are synonymous, and that the practice of obstetrics consi.sts of either 
a professional reception of the baby, the application of forcep.s, or the per- 
formance of a cesarean section. They have not the proper conception of 
the art of adapting therapy to pelvic .symptomatology, the importance of 
matm'C and correct obstetric judgment, the effects of particular opei'ations 
upon the childbearing function, and the numerous factors that subse- 
qxiently influence the patient's psychologic stability and domestic happi- 
ness. As W. T. Smith .said as long ago as 1S58, “they have no methodized 
habits, no illustrative remhvsccnees to throw light upon the obscurities 
which may occur in their sub.scquent pi-actiee. ” They do not seem to rea- 
lize that academic knowledge and the .science of the laboratory can never 
entirel}’’ replace the wisdom of clinical experience. Imbued with such er- 
roneous ideas, and with none to say them nay, they become specialists in 
obstetrics and gyneeolog.v by pronouncement. There are onl}’ two logical 
ways in which this state of alTaii's can be remedied: first by legislation, 
which is impracticable in this country, and secondly by the refusal of the 
lirofession and laity to tolerate the existence of pseudospecialists. 

The term "specialist’' implies that the individual so designated has had 
superior training and has assimilated knowledge from a multitude of op- 
portunities, and the public is ju.st beginning to display an interest in the 
qualifications he reallj^ possesses and to question his authority for so classi- 
fying himself. A specialist differs from a general practitioner in educa- 
tion, not in intelligence. Asa matter of fact, the modern well tz'ained doc- 
tor is essentially a specialist in internal medicine, iiediatrics, minor sur- 
gery, and normal obstetrics. A hospital interneship is requisite to practice 
medicine in but fourteen states, and only six .specifically refer to the appli- 
cant 's attendance upon confinement cases. Uniform standards for licen- 
sure must of necessity be secured by the enactment of legislative modifica- 
tions in the medical practice acts of the different states. These are ex- 
tremelj^ difficult to accomplish and susceptible to political expediency. 
With such inconsistencies in the various laws pertaining to the practice of 



167 


DANNRETJTHBR ; QUAIilFIGATIONS OF THE SPECIALIST 

medicine in general, the suggestion that specialism can be regulated by 
legislation is nothing more than a Utopian hope. But it is not unreason- 
able to expect that if the specialists themselves, with the sanction of the 
profession at large, certify to the proficiencj'' of those who are competent, 
the public, both lay and medical, will be provided with a means for proper 
discrimination, and the State will be enabled to endorse such certification 
Avithout alteration in its medical practice act. 

The justification for the establishment of standards of qualification by 
the medical profession itself, to fix the requirements for legitimate spe- 
cialization, thus appears to be self-evident, and it Avas Avith this objective 
in vicAV that the American Association of Obstetricians, Gynecologists, and 
Abdominal Surgeons, the American Gynecological Society, and the Sec- 
tion of Obstetrics, Gynecology, and Abdominal Surgery of the American 
Medical Association assumed the obligation of creating the American 
Board of Obstetrics and Gynecology. By virtue of the harmonious partici- 
pation and coordinated action of these three preeminent groups of ob- 
stetricians and gynecologists, the Board Avas endoAved Avith an unassailable 
prestige. Its establishment Avas preceded by three years of preliminary 
study and careful planning on the part of the three committees charged 
Avith the task of evolving a satisfactory method of certification. The Avork 
Avas carried on so unobtrusively during the formative period of the com- 
mitteemen’s deliberations, that at the time of the Board’s incori^oration in 
September, 1930, a great many obstetricians and gynecologists Avere un- 
aAA-are of the manner in Avhicli it had been organized and its idealistic pur- 
poses. Not fully appreciating that each of the three National societies had 
elected three PelloAvs to comprise the membership of the Board, in some 
quarters its motives Avere vicAved Avith suspicion, and its personnel mis- 
taken for a self-appointed autocratic group Avho presumed to dictate to 
their colleagues. Voluminous correspondence, perseverance, and cour- 
teous explanations haA'^e been necessary to correct all sorts of misconcep- 
tions, a fcAv of Avhich still prevail. The activities of the Board liaA^e re- 
ceived tlie commendation and support of practically all of the distin- 
guished obstetricians and gynecologists throughout the country, and the 
roster of its certificate holders noAv includes 369 names. Of these, 115 have 
been certified after examination. In June, 1931, the Board Avas notified 
“that the American College of Sm-geons shall recognize the certificate of 
the American Board of Obstetrics and Gynecology as an cAddenee of the 
academic fitness in these specialties of candidates for its FelloAvship Avho 
hold such eeitificates. Such sporadic instances of adA^erse criticism and 
liostility as yet exist are due chiefly to the rejection by the Board of all ap- 
plications from those Avho do not limit their practice to obstetrics and 
gynecology, and to its refusal to certify Avithout examination candidates 
Avho have no more than a local reputation, solely on the recommendation 
of their associates or friends, hlany eligible obstetricians and gjmecolo- 
gists have apparently hesitated to apply for certification because of a not 



168 


A5IERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


unnatural anticipation of embarrassment during tlie course of examina- 
tion. The most trying duty the members of the Board have had to perform 
has been to resist the importunities of those vho are probably well quali- 
fied, but whose compel eney for special practice is unknown outside of their 
respective communities. It should be obvious that personal endorsements 
as testimony of fitness might soon lead to dangerous injustice and a lower- 
ing of standards. The slightest exercise of favoritism, influence, and even 
prejudice would jeopardize the value of every certificate issued. All ap- 
plications have been referred to a Committee on Credentials which is 
chai’ged with the responsibility of classifying candidates. Each diplo- 
mate of the Board who was certified without examination received the 
unanimous vote of all nine examiners, and subscribed to a statement that 
he restricted his practice to olxstetrics or gjniecology; and with compara- 
tively few exceptions, each one was either a Fellow of this Association or 
the American Cjmecological Society or held a professorial rank in one of 
the medical schools. Certification without examination was discontinued 
on December 31, 1931. 

The Board has arranged that no examiner shall participate in the sur- 
vey of any applicant from his own territorial district nor of one with whom 
he is personally acquainted. This pi’ovision precludes violation of the 
candidate ’s professional pride and an insinuation that his attainments are 
in any way disrespected. The object of conducting an examination is to 
discover the extent of the applicant’s knowledge, the character of his prac- 
tices, and his cultural and scientific attributes. Personal evaluation must 
always supplement standardized I’equirements. 

The chief pui’poses of the Board ai'e not restrictive, but educational : to 
encourage and induce potential specialists in obstetrics and gynecology to 
prepare themselves thoroughly, to persuade medical schools and hospitals 
to pi’ovide adequate facilities for special training, and to put the stamp of 
approval on qualified specialists. There is no inclination to curtail the 
professional responsibilities that any licensed physician may care to as- 
sume, nor an implication that a distinguished or well qualified specialist 
requires a further testimonial of his cfipabilities. Neither has the Board 
the desire nor power to control or goveim the pi'actice of obstetrics and 
gynecolog}’-, and applications for certification must always be voluntary. 

Thirty years ago the novitiates in medicine had the benefit of the wise 
counsel and super^^sion of their preceptors, a custom which might well be 
revived. The highest professional ideals, a broad humanity, intellectual 
honesty, and an incorruptible conscience were inculcated in the younger 
men by their seniors. There were but meager institutional opportunities 
for the training of specialists, and that a young man should presume to 
pose as a specialist until he had carried on a general practice for at least 
five to ten years, studied incessantlj’', and served a prolonged apprentice- . 
ship to a recognized authority was unthinkable. That conditions have 
changed materially is well exemplified by the recent statement that it is 



DANNREUTHEE : QUALIFICATIONS OF THE SPECIALlSf 


169 


now relatively easier to be a specialist than it is to be an np-to-date, well 
trained general practitioner. Few modern neopliytes study actively the 
various branches of medicine after graduation, or seem to be concerned 
with the importanee of a firm foundation in general medicine as a basis for 
specialistic ambitions. In a timely address on “Specialism in 1892, 
Osier said, “no more dangerous members of our profession exist than those 
born into it, so to speak, as specialists.” That aphorism is as pertinent to- 
day as it was forty years ago. It is not at all unusual at the present time 
to witness the ex-house officer within six months after completion of his 
interneship alternating with his former attending surgeons in the operat- 
ing I'ooms. He appears seriously interested in curettage, appendectomy, 
and hysterectomy, but he has j'^et to learn that the curette will not cure 
leucorrhea, that pain in the right lower quadrant is usually due to some- 
thing other than the appendix, and that while removing the uterus may 
be the easiest it is not always the best way to arrest nterine bleeding. The 
members of the Amencan Board of Obstetrics and Gynecology believe that 
while the young man under proper guidance may practice obstetrics and 
gynecology safely, he is not entitled to announce himself as a specialist 
until the lapse of at least five years after his interneship, and the devotion 
of three of the five years to intensive training in obstetrics and gynecology. 
This special training need not necessarily be full time institutional work, 
but it must otherwise embrace a satisfactory apprenticeship or postgradu- 
ate education, with concurrent clinical experience under supervision. 
The candidate must demonstrate his proficiency in the diagnosis and non- 
operative treatment of pelvic disorders, and exhibit good obstetric and 
surgical judgment. 

It is almost incredible that with the available laboratory facilities, clin- 
ical pathology should be ignored by those who have the greatest oppor- 
tunity to profit by it and correlate it with their daily Avork. In this respect 
the examinations already held by the Board have revealed an astonishing 
indifference to a knoivledge of the pathology of common obstetric abnor- 
malities and pelvic diseases and neoplasms. It does not seem unduly exact- 
ing to expect one ivlio professes to be expert in operative procedures to be 
familiar ivith the intrinsic pathologic alterations in the tissues involved, 
but it has been apparent that comparatively few obstetricians and gyne- 
cologists have sufficient scientific interest to follow their specimens to the 
laboratory. Ample evidence is at hand, hoAvever, to indicate that many of 
the younger men have been stimulated to read and study so that they 
might be prepared to pass the examination for certification. And those 
Avho have failed once in the examinations already held have endeavored 
to correct their deficiencies or have indicated their intention of aug- 
menting their qualifications before presenting themselves for reexamina- 
tion. These immediate effects of the work of the Board have been very 
gratifying. 

Letters of inquiry have been addressed to the Board repeatedly, asking 



170 


AMERICAN JOURXAE OP OBSTETRICS AND GYNECOLOGY 


Avliorc the M-riters might secuve llie sulvaneccl -work requisite for speeializa- 
lion. but in most cases it has been impossible to direct the applicant 'with 
an assurance of the fulfillment of his aspirations. The comprehensive I’e- 
port emanating from the Medical Service Subcommittee on the Graduate 
Education of Physicians for the While House Conference on Child Health 
and Protection, in 1030, "was based on an accurate and inclusive inventory. 
It disclo-sed that although the institutional facilities for the development 
of specialists in obstetrics and gynecology have been amplified materially 
since the beginning of the century, they are still inadequate in both num- 
ber and scope. Complete unification of obstetrics and gynecology has not 
been accomplished in the majority of medical schools and hospitals. In 
fact, in a numher of the latter it is distre.ssing to note that gynecology has 
not been divorced from the dejiartment of general surgery. The depart- 
mental integration and fusion of obstetrics and gynecology is not only de- 
sirable but highly essential, beeau.se the skillful iiracticc of one is depend- 
ent upon a thorough knowledge of the other. Skill comes not only from 
a maximum of eases, but al.so from the absorption of information derived 
from sound precept and observation. It must be conceded that the large 
Fraucvldinikcv abroad are far better equipped to ])roduce specialists than 
our own institution.s. although the available clinical material is no greater. 
The AYliite Hou.se Conference Committee report stated that “there is a 
total of 1045 obstetric-gynecologic teachers in our medical schools. 
We may conclude that nearly 1000 of them have been self-trained.” 
The following additional excerpts from the Committee’s conclusions are 
significant : 

“Till- oLstetrioiiin wlio doc-s not do the surgery of the lower .nbdomeu is li.ardly 
competent to do the imijor nbdoinin.nl work of obstetrics. 

‘ ‘ The gynecologist who is not in intimate contact with all phases of obstetrics has 
lost much of his perspective in operating on women of the childbearing period. 

“There were 104 .t teachers of obstetrics and gynecology in the United States last 
j’o.nr (19.^0). The v.nst majority of these developed themselves after a more or less in- 
sufficient under-graduate training. 

“Nine graduate schools turned out about 100 trained men: these men worked for 
ye.nrs as subordinates, supervised, and then ,ns their competency was recognized thej 
were given full recognition ns clinicians. 

“ The great majority of men posing as obstetric specialists have had very little train- 
ing: their experience has been gained by practice — and practice does not alw.ays make 
perfect. 

“One large city carries in its medical directory the names of 411 obstetric and 440 
gynecologic specialists. The term 'sirecialist' is well nigh meaningless in this coimtn. 
A new order of being demands that no nmn may pose ns a specialist until he has pro\en 
his ability to so function. ” 

The Board has appointed a Committee on Graduate Education, which 
will undertake to devise ways and means to rectify some of these defects 
in our educational sj^stem. 

The ijublic has a right to expect the medical profession to safeguard it 
from the malpractices of mushroom specialists, and five of the siiecialistic 



dannreuther: qualifications of the specialist 


171 


groups, of wliich we are one, have manifested their disposition to accept 
their share of responsibility, by creating examining boards under the 
auspices of the National societies. The endeavors of these Boards are not 
offered as a corrective panacea for all the defects of professional practice, 
but they can at least wield a salutary influence, especially if they receive 
the active cooperation of their diplomates. The establishment of desir- 
able standai'ds for specialists minus an impartial and widespread applica- 
tion of them would be merely intellectual exercise. The certificates of the 
American Board of Obstetrics and Oynecologj'- can be a protection to local 
obstetric and gynecologic societies as Avell as to hospitals. Several of the 
ophthalmic and otolaryngologic medical societies have made the posses- 
sion of either of these certificates essential for membership, and it would 
be to the advantage of the obstetric and gynecologic organizations to emu- 
late their example. One sectional society has already adopted the Board’s 
standards of qualification as a prerequisite for eligibility. 

Whereas in the beginning the motives of the American Board of Ob- 
stetrics and Gynecology were regarded with considerable skepticism by 
many of our professional brethren, during the past two years the project 
has gained tremendous momentum, and its successful functioning has now 
attracted the attention of other educational groups. A willingness to ex- 
ercise a paternalistic supervision over the activities of the Board has 
already been intimated. In my opinion, nothing can be gained by permit- 
ting it to become subservient to extraneous influences, whatever their pur- 
poses may be. It is not inconceivable that informal contact might develop 
into domination, and finally eventuate in absolute control. The authority 
and powers of the American Board of Obstetrics and Gynecology are de- 
rived from the parent National societies, and it is to these, and only to 
these, that the Board should be answerable. 

It is a tremendous responsibility for anyone even to insinuate that the 
technical practices of another are wrong. Tlie examiners have done the 
best they could at all times, regardless of censure or applause. Nothing 
but the merit of its objectives and its successful accomplishments can per- 
petuate and insure the future existence of the American Board of Obstet- 
rics and Gynecology, and in these I have full confidence. 

580 P.\RK Avenue. 



SO^ilE PHASES OF THE TOXEJiriAS ip PEEGNANCY^t 

\ , 

Bethei. Solomons, M.D., RR.C.P.l., F.C.O.G., Dublin 

(Master of the Jtotumla Hospital) 

'T'HE Rotunda Hospital of Dublin has existed for nearlj^ two hundred 
years. Its bicentenary will be in 1945 and during this period every 
effort has lieen made to keep up to date, to try out the new without for- 
getting tlie old, to remember above all, that obstetrics is a difficult sub- 
ject, that it is a science and an art, and not a trade, and that every effort 
must be made, not only to preserve the life of tlie mother and the child, 
but to discharge the mother Horn hospital healthy and happy ■without 
being marked for life witli the traumatism of labor. 

In addition, as is well Icnown, students, postgraduates and nui'ses from 
all parts of the world arc trained at the Rotunda. This system has gi’eat 
advantages: in their future professional life they will work together 
and it is well they should be brought up together. The segregation of 
nurses and doctors in maternity training has never appealed to me and 
I hope that the custom which has been so long in vogue in Dublin will 
long continue. The presence of these three bodies of pupils should make 
the teacher meticulous in his technic. He must never indulge in any 
small departure from detail for there are no more severe critics of any 
digi’ession than the average student, postgi'aduate, or midwife and there 
is none more ready to adopt such digression as a practice. In other 
words, the child in obstetrics must be taught good manners as the child 
in life is taught in the nursery and example is the best method of teach- 
ing. 

The causes of the toxemias of pregnancy are unknown: the number 
suggested and proved to be causal factors emphasizes this fact. I cannot 
give a full consideration to this discussion within the limits of this com- 
munication: most of the theories ■will be mentioned in order to be dis- 
carded and the only two which can “hold Avater” at all will be discussed. 
These two theories must be taken together : thej’’ are the only two Avhich 
can be proved by clinical results to a large extent and by laboratory 
results to some extent. They are the theories of Young and that sug- 
gested bj'^ Tweedy and held and elaborated at the Rotunda Hospital. We 
have been quoted in the past as stating that “the cause of eclampsia is 
in the gut,” and that “food causes eclampsia.” Both these bald facts 
are incorrect and I desire to refer to the book on Practical Obstetrics, 
which now bears my name.® “AVe know full Avell that food is one of the 


•The Joseph Price Foundation Lecture, presented by invitation, h^ore ^le 
American Association of Obstetricians, Gynecolog'ists and Abdominal burgeons, 
at French Lick Springs, Indiana, September 12, 1932. . . - - - + 

tFor lack of space this paper is published in an 
plete article will appear in the author’s reprints as well as in the current i oluine 
of the Association’s Transactions. 

172 



SOLOMONS: TOXEMIAS OF PREGNANCY 


173 


common factors, bnt we are iu entire agreement with Young and others 
who state that the disease is of toxic origin, that this toxin is almost cer- 
tainly derived from the placenta, either from the chorionic villi or from 
placental infarcts or from the blood. The fact remains that the exact 
toxin has never been found, but it probably circulates in the blood of 
the patient. The destructive changes found throughout the body are due 
to the action of this toxin. This does not explain the whole cause as it 
does not explain why toxemia occurs in some patients and not in others. 
Food is the cause, but not directly as will be shown later. It is Avell 
lmo^vn that all foreign proteins must be changed by the ferments of the 
body before they can be assimilated : if they are absorbed without under- 
going such change they act as irritant poisons. The poison of eclampsia, 
for example, may be explained in this way, on entering the body this 
toxalbumin must be neutralized by the ferments already present if its 
destructive effect is to be avoided. Is it not reasonable to conclude that 
the ferments which effect this neutralization are those which fix the 
amino-acids derived from food ? ’ ’ 

O 


Our view may be summed up bj' the following simple table : 


Food poisons plus toxins of 
pregnancy 

Excess of food poisons. Amino-acids pins 
toxins of pregnancy 

Enough ferment for both 

Insufficient ferment for both, i. e. ferment 
used up for pregnancy toxins 

No toxemia 

Insufficient neutralization 


Toxemia 




Of all the tests in diagnosis of toxemia, there is none more simple than 
the Fouchet test. It is easily done and the results can be reported very 
shortly; it is also reliable in the diagnosis of liver involvement. In a 
former communication^ Bourke and the writer showed it to be most val- 
uable in hyperemesis gravidarum Avithout albuminuria, but that in 
eclampsia and eclampsism, it was chiefiy negative. That is, of course, 
the expected result. 

We cannot agree with CruickshanlcS et al, Avho state that the results 
of tests of hepatic function are of no real service. Enough has been 
said to show our feelings about the intestinal indirect origin. Sugges- 
tions have been made that intestinal hyper permeability leading to ab- 
sorption of toxic intermediate products of digestion, e. g. peptones or 
bacterial metabolism may be the definite cause. Acidosis due to double 
metabolism is a simple thing to claim but brings us no further and those 
who speak of alimentary autointoxication may reiterate, in a different 
waj’-, our own sentiments. 


A theory to support our view is that of Alvarez® who, in his impartial 
leview, summarizes the emdeiice for toxemia of autogenous origin and dis- 



174 


AMEUK'AX JOUUXAL OE OBSTETItICS AND GYNECOLOGY 


i-usses the iinportam-e of the alimentary tract. He, however, concludes 
that the mechanical factor is specially important in causing vascular en- 
gorgement of the intestinal wall, stasis and abnormal permeability. 

As the mechanical factor has been mentioned, Paramore' must be 
quoted. Intraabdominal pressure is his catchword and this, lie says, is 
fundamentally related to general metabolism. The greater the intra- 
abdominal pressure, the greater the return of blood to the heart. Para- 
more's conception that eclampsia is sim])ly a manifestation of a gradually 
perverted metabolism due to an excessive comprc.ssion preventing visceral 
activity, is sujiported by the fact that the levator ani muscles hypertrophy 
in pregnancy, that eclampsia occurs in the strongest women with good 
abdominal walls. Can it be believed, says Paramore, that any specific 
toxin is in play? AVc fear that he has unwittingly evaded the issue. 

TJien Theobald® shows by experiments that albuminuria associated with 
Iircgnancy can be accounted for by mcebanical means, e. g., lordosis, 
diminisbed thoracic capacity of later months of pregnancy, and the 
weight of the uterus. Possibly the damage to the kidney in eclampsia is 
the same as that caused by increasing the pressure in the renal vein. 

jMy late assistant, O’Donel Browne," following the example of my chief. 
Tweedy, tries to .show the relation between blood extravasation and al- 
bumin and applies this to theorize on accidental hemorrhage. It is an 
interesting theory, but there ai'C too many albuminurias without extrav- 
asation of blood, and too many cases of blood extravasation without 
albuminuria, to permit its acceptance. It may, however, lead to some- 
thing. 

Titus’" has stated that “there is a disturbance in carbohydrate metabo- 
lism, but hyperglycemia is not characteristic of eclampsia. As convul- 
sions in eclampsia are to be designated as a hypoglycemic reaction or 
manifestation, insulin with or without glucose is unnecessary and con- 
traindicated. Intravenous in.iection of hypertonic glucose solution has 
a definite basis for its proved therapeutic value.’’ I have the greatest 
respect for Titus, but this does not explain the whole case for treatment 
of the toxemias, nor is it, I am sure, intended to do so. 

James Young,” Avho reiterates the statement that there is some factor 
in eclampsia which causes placental damage must be listened to. He 
proves his point to a large extent, and his theory, taken in eon,iunetion 
with ours, bears close investigation. It is only necessary to read the 
works of Cruickshank and Stander’" to realize how difficult it is to 
theorize on this subject. In summing up the question of theories, Ci’uick- 
shank concludes that if the toxemias of pregnancy have a common cause, 
it is some form of intoxication from the breakdown of placental tissue, 
probably some of the higher forms of protein catabolism which, like the 
breakdown products of lecithin, have a powerful action even when present 
in a small amount. 

The theories of etiology of eclampsia as collected by Standee are: 



SOLOMONS: TOXEMIAS OF PREGNANCY 


175 


autointoxication, fetal elements, fetal metabolic products, placenta, in- 
fection theory, endocrines, biological reaction, mammary, diet, renal ori- 
gin, edema tlieoiy, capillary spasm, ox 3 ^gen deficiencj’’, nervous origin, 
liver, nitrogenous retention, inorganic constituents of the blood, lipoids, 
colloids, carboh.ydrates, acidosis, and h.ypertension. 

A close studj' of this extended list has unfortunatelj’' compelled us to 
refuse acceptance of anj’ one of them. If theories are to be of any real 
value thej' must assist in determining suitable clinical treatment. When 
followed out to the bitter end, it has been found that there has been no 
useful treatment derived from anj' of these. Our own treatment has a 
direct relation to our theoiy of the cause. 


VARIETIES OF TOXEJriAS 

The nomenclature regarding toxemia of pregnancj’- seemed on investi- 
gation to be so inconclusive that a questionnaire Avas sent to various insti- 
tutions and the answers obtained from them will be summed up later. 
To the Registrars of the Institutions and the Chiefs of the Clinics mj’- 
thanks are tendered for their kindness in replying. Unanimity was ob- 
served about certain diseases. All included eclampsia, eclampsism, ]i.y- 
peremesis and acute j’^ellow atropliAL Two omitted accidental hemor- 
rhage altogether. Essen Sloller modified the kidnej’- cases bj’- including 
albuminuria, ivith not more than 10 per cent albumin and nephritis, with 
more than 10 per cent albumin. Herpes, saliyation, chorea, and melan- 
cholia were included in the lists of some of the others. This list could 
be added to enormously but from a practical point of view an increase 
clouds the issue and leads to no beneficial result. It is notCAvortlij'’ that 
accidental hemorrhage is not included in the works of Stander or of 
Cruickshank and his colleagues. 

I desire to discuss briefly': Albuminuria without marked toxemic 
signs and sj^mptoms, eclampsism, eclampsia, hjqieremesis gravidarum, 
and accidental hemoridiage. 

Q C C C' 


AI>BUi\nNURIA, KCLAMPSISM, KCr.AMPSTA 

Such is the simple classification I u.se of the toxemias whose chief and 
cardinal system is albuminuria, because it is simple, it expresses a definite 
thing, and other classifications in my opinion confuse the issue, instead 
of elarifjnng it."' 

^ 5 ! 


Albuminuria . — This refers to a condition in which the patient is ad- 
mitted to the labor ward, simply because of albumin in the urine. She 
is supremely important because if she is not carefully watched she may 
develop eclampsism, eclampsia, or some other type of toxemia. In this 


■'vriting' this Young tJ. Obst. Gynec. Brit. Emp., 30: 2, 3101 has siiErc-Pctori 
cfaes wUh'’ours‘?" the best classiRcation and this practically coin- 



176 


AJIERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


type there are no other symptoms, the blood pressure is often not raised, 
the output of urine is not decreased, there is no marked edema. The 
blood urea is normal and other biochemical tests are usually negative. 
In spite of all this, the patient must be carefully treated and again, 
simplicity is the keynote. We classify albuminuria as follows: trace, 
present, abundant, or solid. The first warns us of danger, the second 
that danger is present, “abundant” suggests cclampsism, and solid that 
eclampsia is nearly always present. 

I have tried all laboratory tests with a view to determining treatment, 
but reliance is placed almost entirely on the clinical manifestation. Water 
is given to the amount of four or five pints daily, flavored with lemon 
.iuice, also glucose. Glucose is given bj* the bowel. Purgatives are given 
at least once daily and enemas, if necessary. If the condition has not 
cleared up in three days induction is done. We used to leave these 
patients four days but a condition of hypoglycemia may arise if starva- 
tion is continued too long. 

Eclampsism . — It is questionable whether a term which suggests “simi- 
lar to eclampsia” is better than a term which suggests “before eclamp- 
sia.” We prefer the former. Eclampsism is eclampsia without fits. 
All the symptoms and signs of the latter are present and the postmortem 
findings ai’c the same. We treat our cases in the same way as we treat 
eclampsia except that morphine is not administered unless the patient 
is very restless, also induction by means of puncture of the membranes is 
done after three days’ treatment without improvement. It must be 
stressed that it is far better to pursue treatment before induction rather 
than induce at the peak of the illness. It is well known that the kidney 
condition does not iinjirove in laboi*, so that a diminution in the amount 
of albumin, a lowering of the blood pressure, and an increase in the 
amount of urinary secretion are all desirable before induction. 

If the amount of albumin is great, if the secretion of the urine is 
small, if the blood pressure is between ISO and 200 sj’-stolic, while the 
blood urea is 100 mg. per cent, induction will surelj’’ be necessary. If 
the symptoms of eclampsism occur in the early months the case is nearlj' 
always prepregnancy nephritis. Termination of the pregnancy is nearly 
alwaj'S indicated in this class of ease and a vaginal or abdominal section 
is usually the treatment in the presence of a chronic nephritis. 

Eclampsia . — In a recent communication’® the writer, with Bourke, 
strewed particularly the nomenclature of eclampsia. Questions sub- 
mitted to various maternity hospitals elicited the fact that “fits were 
necessary in nomenclature.” In this paper several cases were described 
showing difficulty. One was a para iii who had had two normal confine- 
ments. She was admitted in convulsions and with blood pressure 122/70. 
She had routine treatment and was delivered spontaneously of a stillborn 
fetus weighing 4% pounds. There Avere signs of consciousness returning 
and she seemed to be improAung. Later coma returned. Blood pressure \ 
142/70. Blood urea 30 mg. per cent. She then proceeded to have 31 



SOl.OMONS: TOXEMIAS OF PREGNAXCY 


177 


convulsions and died. The postmortem report was atypical lor eclamp- 
sia and exemplifies not only the danger of fits in the multipara but also 
the difficulty of determining whether a patient has eclampsia or not. 

We then proceeded to give the postmortem results side by side with 
those found in t 3 ''pical eclampsia. The case quoted was not an eclamptic. 
She had, however, fits and toxemia, therefore she must be included in 
eclampsia statistics. We define eclampsia as the occurrence of fits in 
a pregnant or puerperal woman which would not have occurred if she 
had not been pregnant. 

Williams does not go so far and defines eclampsia as an acute toxemia 
occurring in the pregnant, parturient or puerperal woman, usually ac- 
companied bj’’ clonic and tonic conruilsions. He states that while the 
eomuilsions are by far the most startling clinical manifestations of 
eclampsia and give the disease its name, instances are occasionally met 
with ill which they are absent. Greenhill,'® in 1926, in his definition 
mentions eonmilsions, but includes also those eases of acute toxemia with- 
out convulsions, which at necropsy show the changes characteristic of 
eclampsia. Greenhill’s definition bears out the difference in opinion on 
this subject. A perusal of his 78 eases, however, shows that convulsions 
tvere present in all. 

We cannot find a definition of eclampsia in the monograph by Stroga- 
noff.^' We fear, until it is otherwise ordained at an International Con- 
gress, that we must include in our statistics of eclampsia (until it is 
proved otherwise) these pregnant or puerperal women who die having 
had fits, unless the postmortem results reveal absolutely atypical lesions. 
If the patient does not die, she too, for the present, must be included, 
and if she does and a necropsy is impossible, then she also is grouped as 
eclampsia. 

Notes of questionable cases could be multiplied many times. 

Since writing this, Stander,^® Ashton and Cadden^® state that in one- 
tenth of their eases diagnosis is difficult. Thej^ recommend urea and 
creatinine excretion tests for routine use in all cases of toxemia of 
pregnancy where the diagnosis is not clear. A urea clearance of below 
80 per cent of the normal and a creatinine excretion below 155 mg. in 
the first hour, are strongly indicative of renal damage. Does the word 
“indicative” mean certain? 


Eclampsia may occur from the sixth lunar month until forty-eight 
hours after delivery although cases have been reported some days after 
this. It is a gi’ave disease at any time. It is most serious in the puer- 
perium of the multiparous patient. In our last investigation of 204 
deaths, the death rate was 8 per cent. In the first five years of the 
present hlastership the death rate was 12.9 per cent. If the true eclamp- 
sism cases are taken with these the mortality rate becomes 6 per cent. 

Symptoms and Signs.— In a communication of this kind these will not 
be dealt with minutely. The warning signs and sjmptoms must be 
treated. These are headache, vertigo, partial or total blindness, pruritus. 



178 


AMEincAK JOUKXAL OP OHSTETltlCS AND GYNECOLOGV 


drowsiness, mental irritability, insomnia, edema, diminislied secretion of 
urine, I'aised blood pressure. A very itcliy nose often precedes a fit. 

As eye .symptoms have been mentioned, it will be of interest to refer 
to a small investigation ol the eye symptoms made at m,y instigation at 
the Rotunda by our consulting ophthalmologist, IMr. P. Crawley and his 
assistant, Dr. L. AVerner. In this inve.stigation 250 eases were examined 
of which 1S6 were normal, and G4 were in toxemic women. Of the former 
186 the eyes were normal in ITt) and abnormal in 7. 

■2- O O tJ C 

Docs it seem as if the retinitis-])roducing toxin is of bad obstetric im- 
port, and have the eases with retinitis done worse than these with albumin, 
but retinitis free? 

The only other sign which must be mentioned is elevated blood pres- 
sure. This is considered to be a most valuable sign In* P. J. Browne.^® 
Tliere is no doubt that the recognition and treatment of warning symp- 
toms and signs followed by ajipropriatc treatment will allow us to ward 
off. an attack. It is not proposed to de.seribo the eclamptic fit nor to delve 
into differential diagnosis. The treatment will be considered in detail 
and it must be remembei’od that every detail must be attended to, and 
that eclami)sism is treated in the same way as eclampsia, except in so 
far as the fit is concerned. 

TREATMENT OE ECl-AMPSIA AS CARRIED OUT AT THE 
ROTUNDA HOSPITAE 

The treatment at the Rotunda lias stood the test of time and seems 
theoretically and practically sound. It is not intended to discuss other 
treatments in detail but some mu.st be mentioned : cesarean section, ab- 
dominal or vaginal. This treatment is the favorite of the gynecologist 
who is practicing midwifery in contradistinction to the obstetrician who 
is practicing the science and art of obstetrics, and this question is truly 
very important if maternal mortality is to be lowered. Some gynecolo- 
gists seem rather to revel in the fact that they only do consulting mid- 
wifery : these men cannot know the sub.iect. At some Utopian time there 
will be a law that only practicing obstetricians may be called into con- 
■sultation on obstetric problems, then cesarean section at sight for nearly 
every complication will be a thing of the past. 

The results of the discussion at the British Obstetrical Congress in 1923 
showed clearly that palliative measures were best, and since that meeting, 
nonradical measures have been popular in Great Britain and Ireland. 
Certainly cesarean section in Ireland met with disaster in the treatment 
of eclampsia. In Greenhill’s interesting paj^er he says that the treatment 
should not be entirely conservative nor entirely radical, but favors empty- 
ing of the uterus in experienced hands. In spite of this a study of his 
moi’tality figures shows spontaneous deliveries with 3.4 per cent deaths, 
cesarean section 6.7 per cent, forceps 9.5 per cent, version and extraction 
14.3 per cent. 



SOI.OMONS: TOXEMIAS OF PREGNANCY 


179 


Apart from radical measures, drugs to bring down the blood pressure 
were popular for a time : this is an incorrect line of treatment for a 
gradual fall in the blood pressure is valuable, a sudden fall sometimes 
means fatality. 

Other treatments such as kidney decapsulation, magnesium sulphate, 
etc., are only small points included in large technics. Once we belong to 
what maj^ be called the palliative school, we must be Eotunda or Stroga- 
noff and in spite of figures the treatment carried out in Dublin seems 
more rational. Great respect must be accorded to Stroganoff for his 
Avork, but it is difficult, bearing in mind the work done by Bollman-® on 
the effect of chloroform on the liver, work showing that chloroform had 
exactly the same effect on the liver as the toxemias, to accustom oneself 
to give chloroform to the eclamptic with the very depressed heart ! No 
more AA'ill be said, but at the risk of repetition our treatment will be given 
in full detail. 

The only changes I have made are the administration of glucose either 
by the mouth or bowel or under the breasts and rarelj* intravenously: 
also A'eneseetion. Although brought up on the_dangers of this last pro- 
cedure, I have been converted to it as a valuable aid in treatment. Eight 
ounces of blood are withdrawn if the blood pressure is over 160 mm. Hg 
systolic and this is repeated daily if necessary. Since adopting this 
form of treatment the incidence of cerebral hemorrhage has been lowered. 

SUPPLEI^IENTARY MEASURES 

Nursing. — Tliis is jit least 50 per cent of tlie treatment. Tlie nurse must be given 
directions especiallj’ wlien the patient has a fit. In addition, we liaA’o volunteers from 
among the postgraduates, to look after the patient. Everything must be ready, the 
gag, the bullet forceps to catch the tongue, the mucus e.vtractor, the spoon with handle 
bound, or the toothbrush to slip in between the teeth. During a fit mucus pours from 
the mouth like water from a tap, and during a fit the patient must be brought over 
Avith her face to the ground, the tongue brought forward, and the mucus removed or 
she Avill surely die. She is placed in a quiet room, not darh, and morphine is given. 
She lies on the side. If she is conscious a purge such as the mist sennae co. of the 
British Pharmacopoeia is given, colon laA’age, gastric lavage, submammary infusion. 

Morphine. — This, is a beneficial drug: it controls the fits and the fewer the fits, the 
better the prognosis. Morphine raises the Co. combining power of the blood and this 
IS of A'alue. Its disadA'antage is its effect on respiration. The rate may go domi to 
4 or 0 per minute, but atropin and oxygen are used to combat this. 

Our routine consists of half a grain Avith the first fit, and a quarter of a grain Avith 
each fit np to two grains in the twenty-fonr hours, but tAVo hours must elapse betAveen 
each dose, tliat is, if the first dose is at six, the ne.xt not to be before eight, the next ten 
and so on. 

Colon Lavage. — Colon loA’age is repeated Avhen necessary, that is if the bowels do 
not move satisfactorily in six hours. Occasionally it may be repeated again but a 
third lavage is scarcely ever necessary. The boAvels should move four or five times 
daily. Also if urine is not being secreted, repeat the lavage, as the toxemic condition 
is preventing the kidneys from functioning. Linseed poultices are applied to the 
loins at tAvo-hourly intervals to favor urinary secretion. 

Gastric Lavage.—Tlns is done when vomiting is a marked symptom or Avhen the 
patient is so unconscious that the only means of giving a purgative is by the tube. 



JSO 


AJIEfirCAX JOUKNAL OP OBSTETRICS AND GYNECOLOGV 


Gastiic ]<u.'ige increases shock so that it is onh' carried out wlieii urgent symptoms de- 
mand if. A purgative sitcli as 3 ounces of mist sennae co. is left in the stomach. 

Snbmammari/ Infimon.—li the patient is not improving, if the pulse is weak and 
thread}, and if there is insufiicient secretion of urine, sodium bicarbonate solution, one 
drachm to the pint, is infused under each breast. This is an important part of the 
treatment. The tcmpcr.ature of the fluid should be between 110° and 115° P., and the 
strictest .aseptic precaution should be taken, otherwise extensive infection and slough- 
ing of the parts may follow. It .should be repeated if the symptoms do not improve. 
Xo nijitter what theoretical objections are advanced to the administration of fluids 
under the breasts, wo still persist and believe in it as a valuable adjunct in treatment. 

Treatment with regard to birth; Forceps are applied wlion the head is in the lower 
strait and all conditions are fulfilled. Ether is the anestliotic chosen. Chloroform is 
a heart depressant and must be avoided. 

Other jioints; If a woman with eclampsia recovers and the baby is not delivered, 
she often goes to full term. If, however, there is the slightest sign of recurrence, labor 
is induced. A woman who has had eclampsia is liable to recurrence, and she should 
not be allowed to become pregnant until she has been .albumin free for six months. 
Even then, slie must be carefully watched in pregnancy. Our results will be given at 
the end of this paper. 

ITypcrcmcsts Gravidarum . — In collecting information from other insti- 
tutions, it was oa.sy to see that the name hyperemesis was often misunder- 
stood. In this communication the name implies excessive vomiting ac- 
companied b}' marked constitutional symptoms and definite signs of tox- 
emia. The true toxemic condition is now easifv diagnosed from the so- 
called reflex neurotic. We do not believe in reflex, and the neurotic can 
be cured without difSculty after ruling tlie toxemic condition out. Theo- 
ries other than those mentioned at the beginning of the communication 
will not he discussed. Probably the acidosis irhieli is present is very 
vital but it docs not tell us how it occuiTed. If a patient who has recov- 
ered from hyperemesis is given the smallest amount of food too soon, there 
■null be a recurrence, with in ail likelihood a fatal issue. 

The cases at the Rotunda are dealt with as follows: If albumin is 
present iu the urine, Icidney function tests are done, but these are unnec- 
essary if the clinical symptoms which accompany^ the albumin are vei’y 
mai’ked. If there is no albumimuda, the Ponchet test is done: if it is 
positive the case is one of toxemia; if not, and there is no albumin, the 
ease is neurotic. There is an exception to this, the possibilitj’’ of such 
nonpregnaney conditions as gastric ulcer, cholecystitis, appendicitis, and 
pyelitis. Once the diagnosis has been made, treatment must be active, 
and in this connection it is of interest to read the treatments adopted at 
some of the maternity hospitals from whom enquiries were made. 

Queen Charlotte’s: Termination when truly toxic. 

Essen MoJIer at Lund: Two days without food, not even water. Beetal injections 
of fluid, in more severe cases insulin. No abortion induced for thirty years. (He 
does not say if there has been any abnormality.) 

Sheffield: Severe cases are rare. Emptying the nterns, rectal glucose and gradu- 
ated diet. 

Manchester: 127 cases, 98 cured, 27 evacuated, 4 deaths. 

New Torh Lying-In: Intravenous glucose, normal saline, corpus liiteum, carbohy- 
drates. 



SOLOMONS: TOXEMIAS OE PREGNANCY 


181 


Coovihe: Purgative, forced fluids, glucose in isotonic strength. Gastric lavage. 
Lugol solution Miii, t. i. d. p. c. 

Bristol: Calcium. Glucose. Vitamin D. Evacuation. 

Cardiff : Isolation from relatives, full feeding, attention to bowels. 

It tvill be seen by these notes that the treatment is varied. In five 
years at tlie Eotnnda, there were only 24 eases tvhich could be called 
true hyperemesis. There were three deaths, a mortality rate of 12.5 per 
cent. 

The treatment adopted is (1) gastric lavage with purgatives left in 
stomach, (2) glucose by mouth if possible, otherwise by rectum, under 
breasts, and in severe cases intravenously. Colon lavage is done in severe 
cases. If urine is not being secreted, linseed poultices are applied to 
the loins: calcium gluconate and radiostoleum appeared to have some 
success in a few instances but this treatment was absolutely unsuccessful 
in other tjTies of toxemia. In this our results differed from those of 
Cameron-i although he used practically the same technic. We have tried 
everj-- treatment that has been suggested, decapsulation, insulin, corpus 
luteum, the injection of the blood of a woman pregnant about the same 
period, but in reallj’’ severe eases the only treatment is evacuation of the 
uteims. The best method during the first three months is by vaginal 
hysterotomy, in the next three months vaginal or abdominal cesarean 
section. Once the child is viable induction by puncture of the membranes 
suffices. Evacuation should be done, if in spite of treatment the pulse 
rate becomes irregular and more rapid and the laboratory tests remain 
unchanged. The general appearance of the patient is of supreme im- 
portance, the pinched haunted look with slight icterus will often decide 
the issue. 

Accidental Hemorrhage . — It is of great interest to find that this is not 
included either in the work of Cruickshank or of Stander. The time has 
come to include it among the toxemias. 

A true toxemic accidental hemorrhage is indeed a toxemia. Every- 
thing points to it. All observers who have tried to theorize on this sub- 
ject have failed to find a solution. There is no doubt that there is bleed- 
ing between the muscle bundles, but what causes the bleeding? Some 
toxin? But no one has succeeded in making any convincing observation 
as to the obvious train of symptoms. 

We do not intend to theorize further except to suggest that, as excessive 
swelling of the endothelium of the vessels of the uterus is a marked fea- 
ture, loss of arterial endothelium occurs, mth transudation of blood, 
through the vessel walls. It is easy to visualize a fiow of this escaped 
blood through the uterine muscle towards the placental site, which may 
cause hemorrhage behind the placenta, forming a hematoma which not 
only separates the placenta but makes its way into the substance. In 
addition to this, disintegration of the muscle fibers allows the hemor- 
rhage to separate them ; and the contractible power of the uterus is lost. 
G-radually this hemorrhage may increase and bleeding occurs into the 



182 


A:.VEUICAX JOUUKAO of OBSTETmCS AND GYXECOLOGl' 


otevine oavity and into tho serous surfaces. Hemorrhages also occur in 
Ihe decidua, even into the aumiolic cavity and the fetus gradually dies, 
i his is l>oruo out by jiostniorteui examinatiou of the uteru.s. It is also 
borne out by the :ippenv;im<i of blood on the serous surfaces of the uterus, 
in the broad liganient.s and in t)jc abdominal cavity. In additiou the 
ajipearance of serum at the vagina, .squeezed Horn the uterus as the juice 
is squeezed Iroin an oi'ange, is furtlier confirmation. The exact cause 
cannot bo ascertained; it is different to that of eclamji.sia; it is nearly 
atsvays prcseid in mviltipnrao. in fact, .so true is thi.s that a tirimigravida 
diagnosed as accidental hemorrhage is mo.st likely to be a placenta prerin. 

Diagnosis is easy, the patient is nearly, but not always, a multipara 
with symptoms of severe collapse, thready pulse, etc,, a uterus painful 
and tender willi imjio.ssibility to feel fetal }>avts, no fetal heart, a vaginal 
examination revealing memhranes bulging and no placenta. 

Our treatment will now ho considered, and it is of great interest to be 
retrospective. On considering the various treatments which have been 
carried out at the Rotunda, it will be found that there has been a gradual 
reeling against radicalism, and the mild measures liavc been attended by 
improved results. During recent years the following treatments for 
severe concealed aeeidenial bemovrhage have been carried out; Vaginal 
plugging, nearly invariably fatal; cesarean hysterectomy, fatal; cesarean 
section, a great improvomout ; and the present treatment. 

One of the most divuimtic episodes the writer has witnessed was the 
fiivst time he saw a uterus left in the abdomen with hemorrhage exuding 
i’rom the serom surfaeo.s, from the ]>eritoncum of the broad ligament, 
from the pelvic wall.s, and the patient recovered. But the resvdts were 
not good and the treatment which is now carried out obtains most extra- 
ordinarily good resvilts, but the details as in eclampsia must be meticu- 
lously observed. The treatment is the same for the severe as for the 
mild cases, except that the former will require more saline and stimulants. 
When the jiatient is admitted she i.s sui’rounded by hot water bottles, 
given two jiints of saline under the breasts. Then the membranes are 
punctured, and pituitary extract given in 2Yo unit doses every quarter 
hour, until if necessary 20 nnits are given. Delivery takes a variable time 
but nsualb^ four to eight hours secs the termination of labor. The pulse 
rate must be carefully observed and any increase indicated stimulants 
and repeated submammary saline. In a severe case intramuscular iujee- 
tion.s of ephedrine, brandy, ether are given at hourly intervals. Morphine 
is a routine statidhy. 

Patients do not die of concealed accidental hemorrhage, if the condition 
is diagnosed in time and the measures suggested are adopted. But the 
pulse must be eai’efully observed and any sudden increase in its rate 
calls for immediate action. 

In the hve-year period there were 132 cases of toxemic accidental hem- 
orrhage with 5 deaths, a mortality rate of 3.7S per cent. 

Prenatal Care . — ^Prenatal care will prevent the occurrence of many 



SOI^OMONS: TOXEMIAS OE PREGNAXCY 


183 


cases of eclampsia, but it will not prevent eclampsism with sometimes 
fatal results. It should however be insisted upon as the incidence of 
mortality will be more lowered bj’’ care and timely induction in the pre- 
natal period. 

Prenatal care is useful in hyperemesis, inasmuch as advice can be given 
before it occurs ; when it is present approijriate treatment can be carried 
out before the patient is fatally ill. 

The onset of accidental hemorrhage is usually so acute that prenatal 
care at the moment has very little effect on prognosis and treatment. 


A SUMMARY OF CASES OF TOXEMIA OP PREGNAKCY DURING FI\’E YEARS 


AT ROTUNDA HOSFITAX. 
1926-1927 

1979 deliveries in Hospit.nl 


1768 on 

the District 


Albuminuria 

360 

No death 

Eclampsism 

21 

No death 

Eclampsia 

12 

2 deaths 


Treatment same as previousl.v c.xcept glucose was started. Morphine reintroduced 
for eclampsia. Pituitary extract in small doses during colonic lavage. This was done 
because it had been stated that in small doses pituitary extract had no eifect on blood 
pressure. I proved this to be definitely untrue. A dose of tAvo and one-half units 
cause a rise in blood pressure so that the use of pituitary extract in this connection 
Avas discontinued. 

In this year's report, the necessity for reA-ision in nomenclature of eclampsia AA’as 
suggested. 

Twelve cases of eclampsia, 2 deaths, one from puerperal sepsis. The other ease aa’Os 
a questionable eclamptic. She had one fit a few seconds before death, probably a 
death rattle. 


Accidental Hemorrhage 23 Avithout mortality. 

20 were toxemic. 

Syperemesis 3, with one death. 

This case admitted Avith icterus. Albuminuria, acetone, diacetie acid. Induction 
March 24, birth 27, Mors April 3, Minor cesarean section Avould have been a better 
treatment. 

1927-1928 

Intern. Extern. 

2062 1717 


Albuminuria 

608 

no death 

Eclampsism 

28 

1 death 

Eclampsia 

18 

1 death 


Biochemical investigations contmue to be made; they are lielpful but not eon- 
clusiA-e. 

Fatal eclamptic B.M.J. July 1928 

Admitted with definite eclampsism; sbe hours after delivery fits started; eight in 
rapid succession. Fifteen hours later respirations ceased but pulse remained for tAvo 
and a half hours P.ir. Cerebral hemorrhage. 

Accidental Hemorrhage 41 cases 1 death 

2.3 toxemic 
Previous toxemics, 7 



184 


AJIERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


Toxemic Death. 

Jf. C. A priiiiignivida, tliirly-five weeks, fits before admission. Blood nressure 
IIS mm. Hg. 

This case has already been described. 

Eclamimisin. 

Death due to cerebral hemorrhage into the loft ventricle and medulla. 


Hyperemesis C cases : 

no death 


Intern. 

1928-1929 

Extern. 

2034 


1805 

Albuniimiria 

564 

no death 

Eclanipsism 

43 

no death 

Eclampsia 

9 

1 death 


Fatal case, typie.al, para i.v of forty who died of sepsis with bronchopneuiuDnia. 
She had chronic interstitial nephritis. E.vtract from this report reads: 

“Prognosis for the multiparous cchamptic very grave and I dread her advent in the 
hospital.” (Rotunda Report.) 

AccUlental Jlcmorrhaac. 43 cases two deaths, 

1. Attended outside, refused to come in, until moribund ; 

2. Scut up with plugged vagina. P. P. H. Mors. 

25 Toxemic 
G repeat 

D}lpcrcincsis 5 eases 1 death 

Fatal case . . . vomiting at five months which continued for two weeks before ad- 
mission. Patient dehydrated, jaundiced, emaciated. No stomach resonance. Fouchet 
positive. Spontaneous labor at twenty-eight ireeks. Deaths three days after delivery. 
P. M. Interstitial hemorrhage into uterus. Kidneys showed diffuse fatty degenera- 
tion of epithelium of convoluted tubules. Glomeruli distended with engorgement of 
blood. Interstitial fibrosis. This is acute on chronic interstitial nephritis. 

Liver; Congestion around central vein with degeneration of liver colls. Old blood 
in this area. Cells in periphery cloudy, swollen. 

1929-1930 


Intern. 


Extern. 

2258 


1724 

Albuminuria 

639 

“Is it a normal occurrence? ’ ’ 
(Report) 

Eclanipsism 

37 

3 maternal deaths. 

Eclampsia 

S 

3 maternal deaths. 


Bclampsiem. 

1. Primigravida; blind, nystagmus, vomiting. Cesarean scetiou, recovery. Mors, 
four days later rvith mental symptoms. 

2. Cyanosed and moribund. Fibrillation. 

3. Eclamptic without tits. Blindness. Mors in twenty-four hours. 

All three eelampties had severe cerebral hemorrhage. 

Accidental Hemorrhage. 41 cases Toxemic. Normal previous pregnancies. 

1 death 

Fatal case. Para viii, secreted no urine during the five and one-half hours in hos- 
pital. 

Acute Toxemia. 

1. Para. An unusual toxemia; half an hour after birth, collapse. Hematoma of 
perineum and vagina without laceration. That is, general hemorrhagic infiltration of 



SOLOMONS: TOXEMIAS OF PREGNANCY 


185 


vaginal wall and cervix. Uterus and vagina plugged. Death. No free blood in ab- 
dominal cavity but uterine sinuses unusually open. Albumin present an P. M. specimen. 

Mypercmesis. 7 cases 

1 death 

Vagina covered with thrush, also mouth. P. M. Huge intestinal distention and 
pure blood in cerebrospinal fluid. Vomiting three weeks before admission. 

1930-1931 

Intern. Extern. 

2169 1755 


Albuminuria 

738 

no death 

Eclampsism 

19 

1 death 

Eclampsia 

11 

1 death 


Three toxemias of unknoavn nomenclature. 

1. M. C., para x. No prenatal care. Fit twenty minutes before death. P. M. 
Eeport atypical. 

2. E. P. McG., para iii with two previous normal births. Two tits prior to admis- 
sion, recovery, then 29 fits, followed by death. 

3. T. A. Pallor, cyanosis, vomiting. Two days postpartum very drowsy and died. 
P. M. Bronchopneumonia. No other abnoi'mal signs. 

Accidental Hemorrhage. 33 cases, 1 death 

21 Toxemic 
1 Repeat Toxemia 

Hyperemesis. 3 cases 

Total Deaths. 1 Eclampsism 

1 Eclamptic 

1 Accidental Hemorrhage 

Eclampsism. Para i. Eclamptic without fits. Admitted for induction because of 
increasing albuminuria. Routine treatment. Low forceps. Bahy toxemic, died two 
days later. P. M. Toxemia. 

Eclampsia. Para ii. Deep coma on admission. Never regained consciousness and 
died with pontine hemorrhage. 

Accidental Hemorrhage. Moribund on admission. Did not respond. 

RESULTS OF FIVE YEARS OP TOXEMIA AT THE ROTUNDA HOSPITAL 

Only the first five years of the present Mastership are considered. During this 
period, there were 10,502 internal cases and 8,719 external cases. As severe toxemic 
cases are all admitted to the hospital, it seems wise to consider 19,221 cases altogether. 

Of these there were 

Eclampsia 62 cases 8 deaths 12.9 per cent 
Eclampsism 128 cases 4 deaths 3.1 per cent 

If both are taken together 190 cases 12 deaths 6. per cent 

Tlic cause of death will be found in the Rotunda Hospital Reports. 

Tliere were 2,899 cases of albuminuria rvith no deaths. There were 3 cases of toxe- 
mia to which it was impossible to give a name. 

These were chronic nephritic cases according to the postmortem examination. But 
they all died. 

Toxemic accidental hemorrhage 132 cases 5 deaths 3.78 per cent 

Hyperemesis gravidarum 24 cases 3 deaths 12.5 percent 

In all excluding albuminuria otherwise than eclampsia without fits, i. e. eclamnsism 
349 cases, 23 deaths, G.3 per cent. ’ ’ 



186 


a:^ikuican aouuxal of obstktjhcs and gvxecologv 


SUM JIAUy AXlJ COXCJyUSIOXS 

1. ilie subject of toxemia ol preguaucy M'as chonen because so many 
points regarding diagnosis and Ireatmoit are still inconclusive. 

2. The cau.se of these toxemias is still unknown. If theories as to 
cau.sation are to be of a.ssistanee, successful clinical results must follo\v 
their application. The two theories. cs])ceially in regard to eclamp.sia 
in M'hich food and placental toxins j)]ay the chief part, seem to he valid, 
a.s they conjorm to ihi.s rule. If patients can be ])ersuaded to attend 
prcnatally thej’ should not, as a rule, die. If they do not attend, no 
treatment will be of avail in some instances, as cerebral hemorrhage may 
occur. Of the S deaths in this scrie.s, 5 had cerebral hemorrhage as shown 
at autopsy and two died of puerperal sepsis. 

o. The x’arieties of toxemia arc numerous. They might he divided into 
(a) common, (b) rare, ruder the former heading would be included 
albuminuria with marked toxic .symptoms, eelampsism, eclampsia, hy- 
porcmc.si.s, and accidental licmorrhage. 

4. Prenatal care must be insisted on. Results will be better, but there 
will still be a small mortality. 

5. The Fouchet test is a .simjde and valuable te.st for liver involvement. 

6. The nomenclature of eclampsia must be decided on at an Interna- 
tional Congress. 

7. The results of an investigation of the eye in toxemia are given. 

8. In evaluating statistics of hyperemesis gravidarum investigation 
should be made as to whether tho.se cases are truly hyperemesis. There 
is no cure for some of tlio.se enses except evacuation of the uterus which 
can sometimes be carried out gradually; at other limes it must be imme- 
diate. 

9. Toxemic accidental hemorrhage, as its name implies, must be classi- 
fied as toxemia. It is nearly always curable if treated as soon as it is 
diagnosed. 

10. A summary of eases of toxemia of ijregnancy during five years at 
the Rotunda Hospital i.s given in which the mortality statistics for eclamp- 
sia, eelampsi.sm, accidental hemorrhage, and hyperemesis graxddarum 
will be found. 


REFERENCES 

(1) Eohnrs, 0. tr.: Medical Essay. 1S42-1SS2. (2) Borland: Atcdic.-il Diction- 

ai’ 3 ’. (3) Solomons ; Tweody’s Practical OUstetvics, ed. 6, 1928. (4) Solomons and 

Eonrhe: Irisli J. M. Se. 65; ‘222. (5) Crnicksliank, Eeiviit, Coiiper: Med. Bese.arcli 

Council, 1927. (6) Alvarez: Physical Rev. 4; 352, 1924. (7) Paramore: Lancet 

11,28 3 2: 914,1928. (8) Tlieohald: L.mcet 31, 10, 31, 2: 948, 1931. (9) Browne: 
Qu,irt. J. oust. &G.ynec. Brit. Emp. 38 •• 3, 528. _ (10) Titus: Am. J. Obst. 14 : 1928- 
9 (11) Young: Qn.art. J. OTost. & Gvnee, Brit. Emp. 34: 2, 19-,^ (1-) Stands) . 

The Toxaemias of Pregnancy, 1929. (13) Slander and Peckhami Ml. L Obst. & 

Gynec 23: 4, 461. (14) Trillmms: Obstetrics, 6th EditionfV( 15 ) Solowmi.v n«d 

pourke: Brit. M. J. 30: 4, 1932. (16) Greenliill; J. A. M. A.^T; 228, 1926. (10 

Siroqanoff: Treatment of Eclampsia, 1930. (18) Standoy Asliton, 

Obst. & Gynec. 23 : 461, 1932. (19) Broione, F. Bnt M. J. Feb. A 193- > 

Ronmaii; Proe. Staff Meeting, Mayo Clinic, 4: 369, 19-9, (-1) Carmen ei a. 

Quart. J. Obst. Gynec. Brit. Emp, 2; 343. 



NEW METHODS OP STUDY APPLIED TO 

MORTALITIES IN THE HOSPITAL^' 


A. J. Skeel, M.D., P.A.C.S., Cleveland, Ohio 

(Birector Division of Obstetrics, St. Lnhe’s Hospital) 

TTOSPITAL standards are established for the purpose of increasing the 
11 average of efficiency. If we are to improve our standards, we must 
have an accurate measuring stick for testing the end-results. 

Durino- the last decade the challenge has been rather sharply made by 
certain medical authors, and by an increasing group of lay writers, reflect- 
iBo- their opinions, that the general hospital is not a safe place for the caie 
of obstetric patients. To be more specific, the statement is made that 
patients delivered and housed in a general hospital, are suboected to undue 


risk from septic infection. 

Statistics are being compiled to .support this view, and are even finding 
their way into obstetric textbooks. Obstetricians responsible for the con- 
duct of maternity wards in good hospitals, knowing intimately the con- 
ditions in their own institutions, have understood the fallacies behind 
many of these conclusions, and secure in this knowledge, have generall:s 
ignored these charges. The recent appearance however of an article by 
a”]ay writer, in a publication of national circulation, urging women to 
avoid the “flaming death” of septicemia, by remaining at home or going 
to a specialized maternity hospital, supporting this view by quotations 
from an obstetric authority of high standing, should not go unanswered. 

The maternity ward in a general hospital, must defend its right to exist 
as such, must show that the safety of its patients is adequately safeguard- 
ed; or tacitly admit as its detractors charge, that it is a mere makeshift, 
defensible onlj’’ because of lack of more adequate facilities. 

Tables of hospital deliveries and mortalities, as compiled by our Bu- 
reaus of Vital Statistics, give rise to several subjects for discussion. 

Pirsf . — Tables which make comparisons between hospitals, based on the 
ratios between live births and puerperal deaths. The inference is lightly 
made that the puerperal death rate for a hospital is a criterion of the 
safety of that hospital for child-birth. The tables of the Cleveland 
Health Office for 1931 make the following comparisons. 


PLACE OP 

LIVING 

PUERPERAL 

DEATH RATE 

BIRTH 

BIRTHS 

DEATHS 

PER 1000 

Home cases 

6516 

19 

2.9 

Maternity hospitals 

3519 

20 

5.7 

General hospitals 

6235 

70 

H.l 

Hospital totals 

9754 

90 

10. 



‘Read at the Forty-Fifth Annual Meeting of the American Association of Obstetri- 
cians, Gynecologists and Abdominal Surgeons. French Lick Springs, Ind,, September 12 
13, and 14, 1932. ’ 

187 





188 


AatERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 

Any lay rcacler might and (to judge from the literature) many medical 
readers do, conclude that child-birth is relatively safe at home, quite 
unsafe in a maternity hospital, and positively dangerous in a general 
hospital. Puerperal deaths consist of deaths from delivery, plus, deaths 
from abortions, miscarriages, ectopic pregnancies and all the other mis- 
haps of early pregnancy. Thei-c is therefore no ivay to rationalize the 
computation of ratios bctivcen births and nyncr-pcral deaths, as a hospital 
study. These tables olTer no information as to hospital efficiency, or as 
to comparative merits of various ho.spitals. 

Maternity hospitals have practically no puerperal deaths except deliv- 
ery deaths. Good maternity hospitals properly refuse to admit abor- 
tions, miscarriages, etc., because it is unsafe to house them in maternity 
wards, or to care for them with the maternity nursing personnel. The 
general hospital accepts these cases in its medical and surgical wards, and 
if death ensues, it is a puerperal death occurring in that hospital. These 
deaths plus delivery deaths arc then ehcelced against the number of births, 
in estimating a puerjieral death rate for the institution. A high puerperal 
death rate in a general hospital indicates merelj’’ that the institution has 
a large gj-necologic and surgical service. It throws no light whatever on 
the quality of its obstetric service: The measure of the efficiency and 
safety of a maternity service, is not the puerperal death rate of the hos- 
pital, but the delivery death rate of its maternity service. This criterion 
is accurate for the maternity hospital, and equally so for the general hos- 
pital. The puerperal death rate and the delivery death rate of a mater- 
nity hospital may not be far different, but in a general hospital with 
active gynecologic and surgical services the puerperal rate is often twice 
that of the delivery rate. 

Second .- — The method of calculation of death rates is wrong. Child 
Welfare Bureaus and sociologists are interested in ascez’taining the total 
number of maternal lives lost in producing, e. g., 100,000 live babies, and 
our vital statistics setup is based on this study. The number of deliv- 
eries occurring in a hospital however, is the number of live births plus 
the number of stillbirths. A birth in our sense is the delivery of a viable 
fetus. The death rate should not be raised by estimating it from live 
births instead of from total births. 

Figures were obtained from the Cleveland Health Office, showing the 
period of intrauterine gestation, for each of the puerperal deaths charged 
against Cleveland hospitals for 1931. We took six and one-half months 
as a basis for separating viable from nonviable cases. The regular tables 
gave us the number of stillbirths, which rve added to the live births to 
obtain the number of deliveries. 

We found 17 delivery deaths and 3 previable deaths at the maternities, 
while the general hospitals had 36 delh’-ery deaths and 34 previable. The 
official tables showed 110 stillbirths at maternities and 240 at general 
hospitals. Tabulating the comparative results we have the following : 



skeel: maternal mortalities 


189 



OFFICIAL FIGtTEES 
PUERPEEAL DEATHS 
PEE 1000 LIVINQ 
BIRTHS 

DELIVERY DEATHS 
PER 1000 LIVING 
BIETHS 

CORRECT FIGURES 
DELIVERY DEATHS 

PER 1000 TOTAL 
BIRTHS 

Maternity 

hospitals 

5.7 

4.S 

4.7 

General 

hospitals 

11.1 

5.8 

5.5 

Hospital 

totals 

10. 

5.4 

5.2 


Tlie general hospital ratio is diminished from 11.1 to 5.5 and the total 
hospital figures from 10 to 5.2 by correct analysis. The official Cleveland 
figures are not unique, but are standard forms. Why do we permit the 
publication of an anachronism so misleading regarding hospital efficiency 
for obstetrics as a whole, and equally misleading when used to compare 
the relative safety of different types of obstetric services? The entire 
cause of American obstetrics is suffering from a lack of appreciation of 
the difference between puerperal death rates and delivery death rates. 
Puerperal death rates are a more appropriate subject for a Sunday morn- 
ing sermon than for comparison of hospital mortalities. 

We turn again to Cleveland’s official tables. The Cleveland City Hos- 
pital had 884 deliveries, with 12 viable and 13 previable deaths. It is 
like most other city hospitals, a dumping ground for infected eases. 
Omitting the City Hospital from the list, in order to get a fair idea of 
the average work of our general hospitals, we find the delivery death rate 
of the general hospitals, to be 4.5, that of the maternities was 4.7. Allow- 
ing for minor errors in estimating viability, etc., the delivery death rate 
of the two types of institutions was practically the same. 

Comparison of hospital deliveries with home deliveries, basing this com- 
parison on the respective death rates, seems to be a favorite pastime for 
statisticians and lay authors. Disproportion, placenta previa, eclampsia, 
and cardiac disease, are the cause of nearly all nonseptic deaths following 
delivery. Practically all of these become hospital cases either before 
or during labor. Delivery occurs in the hospital, and if death ensues it 
IS a hospital death. These women are sent to the hospital, because the 
acihties, technic, and professional skill which the institution provides 
can save many of them who would certainly die at home. This is common 
Imowledge, yet we permit without effective protest, the publishing of 
comparisons which are utterly misleading. The entire subject of hos- 
pital maternal mortalities needs detailed continuous study by obstetri- 

Cl&XlS, 


THE CLEVELAl^D PLAK 

Early this year at a conference of the obstetric heads of several Cleve 
land hospitals, an organization was perfected to give this matle tS' 
ous attention, and to assemble the information so obtain^ able' 
form. Every hospital in the city with an organized mater lity depart 




190 


AMEIUCAX JOUHXAI, OF OBSTETKICS AND GYNECOLOGY 

moot, is invited to participate in ouv conferences. The only requiremenl 
is that, the hospital shall cooperate by making detailed reports of its own 

puerperal deaths. For the jnirpo.se of this study we have ela.ssified these 
deaths as follows: 

A. Puerperal float Iis 

(1) A’iable (following fleliverio.s) 

(2) Proviablc (following abortion.*:, ectopic’.*!, etc.) 

B. Viable * - 

(1) .Septic 

(2) Nonseptie 

C. Septic 

(1) Iiitra hospital infections 

(2) Extra hospital infection.s 

D. Xonsoptie 

(1) Sent to lio.spital for known pathologic conditions 

(2) Admitted as normal cases 

We accept 1500 gm.. or six and one-half months, as the period of viabil- 
ity, In the nonscjitio group fall the cases of late toxemia, eclampsia, 
late hemorrhages of placenta jircvia, and ablatio placentae, cases of ear- 
diae disease, shock, early jnicumonia, early emboli, etc. 

In the .septic class we jilace all the frank infections, the late pneumonias, 
late emboli, nonohstruefivo iIou.s, etc. Patient.s admitted with fever or 
developing fever witliin twenty-four hours after admission, are ela.ssed 
as extra hospital infectious. Patients admitted after intrauterine manipu- 
lations, .such as unsterile jiacking for jilacenta previa, prolonged attemjAs 
at delivery by forceps or version, are also considered extra hospital infec- 
tions. 

The grouji consisting of obstetric sj^ecialists from the vaiaous hospitals, 
sits as a .jury on eacli case. Each hosjntal presents its own report with- 
out naming either patient or physician. These reports not only give 
information fi-om the chart record, but additional facts obtained from 
the attending physician. The reports are checked by our secretaiy, Avho 
obtains from the Health Office, records of all jnierperal deaths. 

Seven of our general hospitals, with approximately 13,000 births in 
the year.s 1929, 1930, and 1931, sJiowed 17 sejitie cases which terminated 
fatally. I’en of the.se were of extra hospital origin. In 7 no extra 
hospital cause was evident. Not all of those however shoiild be attributed 
to hospital conditions. Late coitus, self examination, and personal un- 
el eanliness, are well recognized sources of vaginal contamination at the 
time of labor. It is also apparent that the 10 eases of exti'a hospital in- 
fection, and many other similar cases occurring in other hospitals, should 
be added to the deaths attributed to liome deli\mries. 

We feel that here is a field, -well desei'ving study over long periods and 
by many groups. Valuable information of a type not now available 
could be acquired by tliis means. It is in the hope of stimulating such 
group study, that we have presented onr plan. 



skeel: maternal mortalities 


191 


The writei’ has no desire to defend carelessness in the supervision of 
obstetric work in a general hospital. Anj" institution which permits 
medical, surgical and obstetric patients to be housed in the same units, 
and to be cared for by the same personnel, is inviting tragedy. He does 
believe however that the suitably placed obstetric unit, serviced by a 
properly segregated personnel, and adequately supervised, is safe from 
the mjdh of “air borne” infection. At St. Luke’s the following precau- 
tions are taken to ensure proper isolation of the obstetric division. 

A. Labor rooms, deliverj^ rooms, and obstetric surgery, are cntirelj’ isolated physi- 
cally on the top floor, with no corridors connecting with any other part of the hospital. 

B. Patients ’ rooms, nurseries, etc., on the third floor, directly beneath the delivery 
rooms. The connecting corridor is closed b}' folding doors, which may be opened only 
for purposes of fire or other emergency. 

The following rules and regulations are rigidly enforced: 

1. Before student nurses begin their services in the maternity department, they 
shall be away from the hospital for a day. During the day, they must take a bath, 
shampoo, change all their clothes and have their shoes cleaned. 

2. (A) No nurses who are working in the maternity department shall be per- 
mitted to work in other departments. (B) Nurses working in other departments shall 
not be permitted to work in the maternity department. 

3. All nurses working in the maternity department must pass a rigid inspection of 
fingers, hands, and arms, by the resident or tlie assistant resident and the supervisor 
of obstetrics, when they come on duty. 

4. Maids and janitors working in the obstetric department, must pass a daily in- 
spection before they begin work. 

5. All linen from the obstetric division shall be laundered separately from the 
other hospital linen. 

C. Patients with fever or other evidences of infection, shall be promptly removed 
from the obstetric division. 

There will of course be many necessary variations from the details of 
these rules ; but anj^ hospital general or specialized must accept the prin- 
ciples of isolation upon which these rules are based, if its patients are to 
be adequately protected. 


CONCLUSIONS 

The ratio of puerperal deaths to live births in hospitals, throws no 
light on their relative efficiency. The custom of presenting such com- 
parisons for this purpose is misleading and should cease. 

Properly administered and well supervised obstetric departments, 
whether in general hospitals or in specialized maternities, show similar 
obstetric mortalities, although their puerperal mortalities may be quite 
different. 

We have presented a simple and inexpensive plan for continuous study 
oC obstetric mortalities as found in our large city hospitals. We believe 
that such group studies will lead to more careful diagnoses, stimulate 
autopsies, and develop improved methods and higher standards. 

lOulo Carnegie Avenue. 



W2 


AMERICAN JOURNAL OP OBSTETRICS AND OrNECOLOOE 


ABSTRACT OR DISCUSSION 

DR. JAMES R. McCORD, Atiasta, GA.-ORstctric mortDRj- mvst be considicred 
in tenm of obstetno enre and obsfotrie environment. It is my opinion that the im- 
provement of obstetric environment is more rapid tiian Hint of obstetric care. 

In considering tiie mortality statistics of the average maternity hospital and the 
nieragc general hospital, I fliiiik that the diltercnce is not iiecause of Hie hospital^ its 
S 3 stem, isolation, etc., but hceuusc of the better obstetric judgment that is more 
generallj- obtainable in the maternity hospital. 

Dr. Skecl made the following st.atcment, “The entire subject of liospital maternal 
mortalities needs detailed continuous study by obstctriciams, ” 

Z nottid paraphrase that sentence as follows: The entire subject of hospital mater- 
nal mortalities needs detailed and confimtous teaching, b}* obstetricians, of physiologic 
labor along safe, sane, and conservative lines. 

It has been my privilege to assist in the individual study of some 7300 maternal 
deaths ocenrr/ng in this country. Of those deaths that were probably preventable, 
where lay the fault f In a certain number unquestionabi}' with the patient herself — 
but in a vastly larger group the fault was an error of obstetric judgment. Hospitals, 
equipments, s 3 ’stcnis, nurses pale info insignificance when compared irith a thorough 
knowledge of the pln’siologj* and mechanism of labor. I have made the statement 
man}' times that if obstetric mortalit}’ and morhidif}' are to be pcrmanentl}' improved 
in this eountr}-, it will be bccatiso medical .schools are consistenH}' graduating doctors 
well trained in the fiiudamcutals of the obstetric art. To obtain the maximum of 
improvement, women must bo educated to an appreciation of the fact that obstetrics 
is an art — and taught what good obstetric care really is. Studies of maternal mor- 
talities, as outlined arc instructive and stimulating, but in the final anal 3 'sis obstetric 
mortality is a direct responsibility of our medical schools and obstetric teachers. 

DB. JAMES R', JtlLLER, Hartfoud, Coxn . — When we consider our figures for 
hospital deliver}' mortality, I think we should also compare certain other data, such 
as population of the different cities, or the percentage of hospitalization which occurs 
in any community. Where Negroes, French Canadians, Irish, or Boles are numerous 
the mortality is likely to be higher. In communities where Russians, Italians and 
Jews make up the largest part of the hospital population the mortality should he very 
low. 

I can second the idea pnt forth by Dr. Skccl that the separate unit in a general 
hospital can be run succcssfull}' wtU a low mortality. Our hospital has made a study, 
covering fifteen years and the mortality is shown to be nnder 0.28 per cent, in spite 
of a very liberal use of cesarean section and of intCTference with low forceps. This 
covers the private cases. My own experience on the ward serwc for over twelve 
years shows an exactly equal rate. So we feel that the restrictions put upon the 
general hospital are not thoroughly warranted. The hospitalization figures in Hart- 
ford run up to 87 per cent, and, of course, our statistics are diluted by a large number 
of normal eases. If one compares the death rate reported by DeLec for the Lying-In 
Hospital in Cliicago, 0.237, -with the Royal Maternity in Glasgow of 2.7, it is obvious 
that it is not eleven times more dangerous for a woman to have a baby in the latter 
liospital than in DeLee’s, The whole setting of the institution has to be taken into 
consideration. The Royal Maternity is the dumping ground for all bad obstetrics. 

In comparing different institutions these differences must be kept in mind. 

DR. CHARLES S. BACON, Chicago, III.— I agree that there should he a change 
in the way of collecting statistics. To compare delivery statistics with the statistics 
including all the postabortal deaths is confusing. The number of deaths follo-mug 
abortions may vary greatly; I believe they have increased in recent years. T a , 
of course, would increase the puerperal death rate. There should he, then, a delivery 
death rate and a postabortal death rate considered separately. 



SKEEL: MATERNAL MORTALITIES 


193 


The efforts that are being made in Cleveland to have cooperation of the hospitals 
in maternity records, seems to me of great importance. So far as I hnow that has 
not been done in any other large city, and it cannot result in anything but a great 
improvement, not only in the study of the maternal death rate and maternal morbid- 
ity, but also in the improvement of the technic. Unless that is done, can nre expect 
any improvement in obstetric teaching? The teaching is done largely in the fifth 
year, on the interne service. If the interne teaching is not done properly, didactic 
teaching -svill be of little value. This cooperation of the maternity divisions of the 
hospitals should improve not only the interne teaching but the general technic, -which 
■will go far toward improving the statistics. 

DE. SKEEL (closing) .—Dr. MendenhaU is quite right; this is a protest against 
the publication for general consumption of figures comparing the work and efficiency 
of general hospitals and maternity hospitals, on the basis of puerperal mortality 
instead of delivery mortality. We merely analyzed the ofScial figures, and showed 
that the delivery death rate of the two types of institution were the same. This 
shows the fallacy of the present methods of comparison. 

The group study method has proved verj’- satisfactory in Cleveland. It has devel- 
oped a proper basis of classification, and shows the erroneous conclusions arrived at 
by older methods. 

Another advantage of such a group organization is: when we as a group make 
certain recommendations for hospital care of patients, that recommendation goes to 
the hospital superintendent with more authority than when merely urged by a member 
of his staff. 

With regard to home delivery death rates, we have been able to demonstrate that 
home deliveries in Cleveland are practically normal deliveries. If a patient has 
demonstrated disproportion by long labor at home she is sent to the hospital; if she 
develops eclampsia, she is sent to the hospital; if she shows signs of placenta previa, 
she is sent to the hospital. Yet comparative death rates are published as if the two 
conditions were parallel. Some -writers accept these comparisons as if they demon- 
strated hospital inferiority. In fact they demonstrate its recognized superiority. 


Matters, E. Francis: Torsion of Ovarian Cyst With Bradycardia. Brit. M. J. 1: 

1022, 1931. 

The author reports a case of torsion of a parovarian cyst in a twenty-year-old 
girl with a preoperative pulse rate of 32. The pulse slowdy returned to 81 shortly 
after the operation. An inflamed appendix was also found. The writer theorizes 
that the torsion stimulated the vagus nerve thus slo-wdng the heart, producing 
this deceptive sign of peritoneal involvement. Arthur B. Hunt. 


Stahnke, E. N.: Diminution of Pain in Operative Gynecology and Obstetrics. 

Monatschr. f. Geburtsh. u. Gynak. 87: 144, 1931. 

The anesthetic which has the lowmst mortality is ether which causes on the 
average only one death in 5,000 cases. The next safest anesthetic is lumbar anes- 
thesia. The German figures for nitrous oxide are unsatisfactory. The death rate 
from avertin has not yet been determined. Where deaths from postoperative 
pneumonia are considered, ether exacts the greatest toll. Concerning damage to 
the heart and blood vessels, nitrous oxide is the greatest offender, and ether the 
next. Likewise lumbar anesthesia and avertin produce disturbances in the cir- 
culatory apparatus. Nitrous oxide and lumbar anesthesia, on the other hand 
never cause damage to the liver and kidneys but avertin produces serious and 

ether mild disturbances. Lumbar anesthesia is the only one which brings about 
nerve injuries. ° 



PREVENTION AND CONTROL OP MOR)3JDITY AND MORTALITY 
PRO^I , PUERPERAL) INFECTJQN BY STATE OR ]\rUNICIPAL 
SUPERVISION AND INSPECTION*' 

Charles S. Bacon. Pn.B., i\LD., D.Sc., P.A.C.S., CmcAGO, III. 

A CCORDING to tlic Inlernatioiiiil list of the causes of deaths that is 

iiou adopted by llie United States Census Bxii’cau, puerperal infec- 
tion comes under three headings: Abortion with septic conditions (Head- 
ing HO), ectopic ge.station with septic conditions (142a), and puerperal 
septicemia (145). It should include pucrjjeral phlegmasia alba dolens 
and sO])tic embolism, which are now combined with sudden death in head- 
ing HS. The moi'tality rate is generally com])utcd as the ratio of puer- 
peral deaths to one thousand live birth.s. When deaths from abortion are 
included in pueri)eral mortality it would evidently be more reasonable to 
compare the number of deaths with the number of both live and dead 
birth.s, including under the latter tcj'ui all aboj-fions. Because of the diffi- 
culty of getting report!^ ni' abortions and for other reasons, tlm other 
method of calculating death rates is genei’ally adopted What particu- 
hady interests us in ob.stcfric practice, however, is the delivezy mortality 
rates, i. e.. the I'atio of the number of delivei’y deaths to the nuizzber of 
children of viable age both dead and alive. Abortion is quite another ob- 
stetric problem. The causes of intra- and postabortal mortality are so dif- 
ferent as to require special consideration and the treatment of abortion is 
quite different from that of labor with viable child. The eases are also 
handled in special departments of hospitals. i\Ioreover the frequency of 
abortion varies in diflerent jzcidods and if its statistics are combined with 
those of labor and jmerperizim, they will cause confusing fluctuations. We 
shall be obliged, however, to base our discussion on the generally accepted 
zziortality tables. 

We do not propose to compare the puerperal moz’tality in the United 
States with that of other countries nor that in the diffei'ent states or cities 
or rural districts nor that in hospitals versus hoznes. Several recent papers 
by both Aznerican and Ezzropean writers have made valuable eontrihu- 
tions to these qizestions. We start out with the genei’allj' admitted fact 
that the mortality z'ate is higher tliazi necessaiy and that in the coimtz’y at 
lai'ge it has ziot decreased zizuch izi recent years. Only izuei’peral infeetioiz 
is considered because that is in the list of repoi'table infectious diseases in 
many states and hence, the principle is alreadj'' established that it is the 
duty of the state to seek to control it. No serious effort has yet been made, 
however, bj^ any state to carrj' ozzt a system of adequate supei'vision of lios- 
pitals and private practice that would procure results. We shall attempt 


•Read at the Forty-Fifth Annual Meeting 
cians, Gynecoiogists and Abdominal Surgeons, Kiencii LicK . » < • 

13, and 14, 1932. 



BACON-: PUERPERAL INFECTION 


195 


to show that because of the failure of other efforts the states should now 
undertake this task. 

The methods of supervision^and inspection would probably differ in dif- 
ferent states. Whether it be undertaken by the State Department of 
Health or Department of Public Welfare, or Avhether it be delegated to 
municipal or local health bodies will depend upon the organization that 
has developed and that now functions in different states. If the need of 
supervision is recognized in all the states and the right and duty of the 
state to interfere is accepted, the ways will be found. 

Probably some uniform s.ystem of hospital scoring would eventually be 
introduced. On score cards, similar for example to those used in milk 
eontrol, would be recorded, the rating of the hospitals in equipment, organ- 
ization of the maternity service and performance. The relation of mor- 
bidity to mortalit}*, i. e., the number of eases of puerperal infection to the 
number of deaths would be established as it is now done in the Appraisal 
Form for city health work of the American Public Health Association. 
Scoring of the maternit}’^ work in the different cities, towns, and rural dis- 
tricts could be carried out in a similar waj”" by the state depax’tment. 

In introducing hospital supervision and control of puerperal infection, 
it might be well for certain cities to experiment and try out their own plans 
in order to find out which works most satisfactorily. The best way to se- 
cure hospital and professional cooperation, determine the requirements 
for hospital equipment and organization, and the frequency and nature 
and cost of inspection, etc., could thus be established. An attempt to se- 
cure agreement upon the principles underlying state inspection and upon 
the best way to cany it out could be made by discussions at the annual 
meeting of the State Health Officers with the Surgeon General of the 
United States Health Service. Naturally the matter would also come be- 
fore the American Public Health Association, as well as the American 
Medical Association, the American College of Surgeons and other medical 
societies. 

The state can, and does, exercise authority over phj^sieians and hospitals 
in the matter of vital statistics, ivhen it requires reporting of births and 
deaths, and specifies hoiv reports shall be made. In other ways also the 
state shows its power to control medical practice. Physicians, midwives, 
and nurses must be licensed after examination, and their licenses may be 
revoked for incompetency or misuse. Hospitals also must procure licenses 
and this implies the right of the state to inspect the character of the per- 
sonnel, the equipment, the rules, and the management. Likeivise the state 
has the right and the duty to prevent and control contagious diseases. 
This gives the state the right to inspect maternity hospitals, demand 
proper equipment and the establishment of rules for the prevention and 
eontrol of puerperal infection, because this is an infectious disease. In the 
ease of patients delivered in their homes, infection is in the same category, 
reportable infectious diseases, as other kinds of infection or contagion. 



.196 


A1\IERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 

like scarlet fever or typhoid. Reports of cases of puerperal infection can 
be required, and if deaths occur where no report has been made, the at- 
tending physician can he punished as when death occurs in a case of unre- 
ported scarlet fever. 

Other metliods of preventing mortality from puerperal infection have 
pioved insufticient. The Fellows of tliis Association know that the mor- 
tality from puerperal infection over the whole countiy has not been sub- 
stantially reduced in the last fifteen or twenty years. This is true in spite 
of efforts on the part of members of the profcs.sion and of the laity. Better 
obstetric teaching has been advised and better training of nurses and mid- 
wives; prenalal clinics haA’'e been established. For seven years under the 
operation of the Sheppard-Towner Law, the resources of the general gov- 
ernment were added to those of states for this purpose but apparently Avith 
little result. The Sheppard-Towner Law no doubt has caused a consid- 
erable lessening in the death rate of infants. It did good in educating the 
people to the appreciation of the importance of good obstetric care and 
calling the attention of the medical profession to the needs and demands of 
the community. It is not unlikely that in time it would have accomplished 
something in z’cducing puei’peral infection, but that ivas too big a problem 
to bo soh'ed in seven years. One of the chief aims of those Avho adminis- 
tered the law was to care for pregnancy through the establishment of pre- 
natal clinics. This Avas imiiortant and probably had some effect in dimin- 
ishing accidents of pregnancy, including toxemia. Infection occurs, hoAV- 
ever, during, and shortly after labor and is controlled by prenatal clinics 
only as thej" improve the health and inci’easc the resistance of the graAudae. 

Better education of medical students and of nurses and midwiA’-es ought 
to accomplish something. Parenthetically, it may be said that midAA'ives 
haA'^e generally been ignored by medical schools and are probably neither 
better nor Avorse now than tAventy years ago. Their practice is declining 
in most sections of the country and if infection is more common AAUth them, 
this fact should shoAv in the improA'cment of the mortalitj’’ rates. In 
European countries Avhieh have Avell trained midwiA'^es, the incidence of in- 
fection in their practice is said to be less than in the practice of physicians. 
More attention has been giA'^en lately to obstetric teaching of embryo doc- 
tors and nurses. "Wliy has this failed to produce results ? Didactic teach- 
ing does not help much in preAmnting puerperal infection. Clinical teach- 
ing is of chief importance. Here the trouble lies. PeAV schools have 
enough clinical material to furnish 25 to 30 cases for each student, the 
number that is agreed upon as a minimum. Often the eases are not used 
to best advantage. The most important clinical teaching comes in the in- 
terne year. It is given mostly in general hospitals, not under the control 
of school teachers. Here the student often learns a poor technic and a 
highly developed meddlesome midwifery. Wliat can be expected of a 
young doctor emerging’ from a hospital Avhieh has a record of 30 to 50 per 
cent of forceps operations and a proportional number of Aversions and 
cesarean sections done mostly by general practitioners. 



bacon: puerperal infection 


197 


Tlie great increase in tlie number of patients delivered in hospitals, 
which has now reached about 66 per cent in the cities with hospital accom- 
modations, was at first hailed ivith joy as promising great improvement in 
obstetric practice, but recent studies in this countr}^ and abroad seem to 
show that it has not improved the mortality rate from puerperal infection. 
The number of obstetric operations has increased. Patients are coming 
to demand short and painless labors. The enormous increase in operative 
interference is not accompanied by increased operative skill on the part 
of the physician, nor satisfactory equipment and technic in the hospital. 
This leads to increased infection that is largely responsible for our failure 
to improve our mortality and morbidity rates. 

One fundamental mistake made by general hospitals that accept ob- 
stetric patients is the failure to separate these patients from the rest of 
the hospital. Frequently no preparation room is provided. Patients are 
prepared in the surgical preparation room or in the delivery room. No 
special internes and nurses are provided for the delivery room. Puerperae 
and medical and surgical patients are kept in the same wards, use the 
same bedpans, and are eared for by the same internes and nurses. Man- 
agers of small hospitals will say that it is impossible to separate obstetric 
patients and provide separate obstetric and nursing care for them. The 
obvious answer would be that these hospitals should not be allowed to re- 
ceive obstetric patients. That would hold for cities Avhere proper accom- 
modations could be found in other hospitals. In small toivns, lioivever, 
this ansAver AA'ould not be accepted. When a small hospital is built, it 
should be planned so that rooms to be used for maternity patients are 
separated from the rest of the hospital, so far as possible. Special caution 
in caring for patients Avould avoid much of the danger. Frequent inspec- 
tion of such hospitals Avould, if Avise and thorough, help much. 

Efforts have been made by the American Medical Association and the 
American College of Surgeons to improve hospital methods. Perhaps 
some progress can be made in this Avay, but these bodies lack the authority 
of the state Avhicli by its licensing poAver can command AAdien the associa- 
tions can only advise. The Cleveland plan of cooperation of the maternity 
departments of hospitals described by Dr. Skeel, is more promising if it 
could be generally adopted. While the state cannot, and should not, dic- 
tate the practice of physicians, it can require proper conditions in hospitals 
for safe operative interference and management of normal labor. That 
such a supervision Avould be supported by the best hospitals is shoAvn by the 
results of a questionnaire sent to the hospitals of Chicago a few years ago 
by Dr. Bundesen, Commissioner of Health of the city. The general plan of 
inspection and the rules about to be given Avere generally approved. Well 
appointed and Avell managed hospitals have nothing to fear from such a 
plan and believe that it Avould be a help to carry out their oAvn regulations. 
It would be foolish of course to ignore the difficulties in the Avay of a health 
administration that should inaugurate such a hospital supervision. Loav 
grade hospitals and physicians Avould object Aidien their faults were dis- 



198 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


covered and corrections demanded. No health officer could withstand the 
political pressure that would be brought to bear upon him unless he had 
the support of the medical profession and of the welfare-conscious groups 
of la.ymen. 

The following reeommeudations for the installation of a s.vstem of hos- 
pital inspeef ion or supei’vision including rules for control of puerperal in- 
fection arc jiresented for your consideration. 

RECOMMENDATIONS FOR HOSPITAL INSPECTION 

Puerperal fever is an infeclion of the birth canal due frequently to mis- 
takes in the technic of delivery or in the care of the patient after delivery 
and hence is, Avith few exceptions, preventable. Confinements, like surgical 
operations can be conducted much belter in hospitals than in homes, pro- 
vided that the hospitals are properly equipped for the care of maternity 
eases and that proper rules for their management arc made and enforced. 
It is the duty of the Health Depai-tmcnt to ascertain that every hospital 
Avith an obstetric department has proper equipment and techuie AA'hieh is 
continuoiLsly enforced. For this reason the Department should institute 
a system of inspection, either by the creation of a Bureau of Hospital In- 
spection, or by adding full time physicians as hospital inspectors to the 
proper existing Bureau of the Department. 

Besides the duty of helping to prevent and control the spread of puer- 
peral infection, such inspectoi's could also be entrusted with a similar 
function in other hospital infections in the medical, pediatric, and surgical 
departments and in the inspection of the general hospital sanitation. 

The persons selected as hospital inspectors should be full time physi- 
cians AA'lio liaA'C had hospital cxpci’ience, either on the resident or attend- 
ing staff as AA^ell as considerable experience in the management of conta- 
gious diseases. They should have tact and common sense and understand 
that as representatiA'CS of the Health Department they are to cooperate 
Avith the hospital for the good of the patients and not create antagonism by 
arbitrary actions. 

The inspectors should Ausit the hospitals frequentljq Aveekly if possible, 
especiall5’’ those in Avhich infection is found to exist and those poorlj^ organ- 
ized and equipped. At the first Ausit thej'’ should see that the preparation, 
labor and delivery rooms are properly equipped, that an efficient technic 
in the deliAmry room and the puerperal Avards has been inaugurated and 
that the records are properly kept. Thej'" should see that rules of technic 
are formulated and posted and if necessary the}'’ should assist in making 
or revising such rules. At later Aiisits they should examine all records of 
eases with puerperal fever and suggest measures to prevent the continu- 
ance of the causes. 

GENERAL RULES FOR CONTROL OP PUERPERAL INFECTIONS 

The foUoAving general rules are recommended to hospitals to prevent 
puerperal infection. 



bacon: PUERPERAli INFECTION 


199 


I. Tlie obstetric staff of tbe hospital shall be responsible for the formu- 
lation of rules, for the management of the delivery room, and for the care 
of the puerperae and for the carrying out of these rules. 

II. To prevent infection during labor the following things should be 
noted ; 

a. Vaginal examinations shall be made onty after thorough aseptic 
preparation of both patient and examiner. In making rectal examina- 
tions everj’’ precaution shall be taken to avoid contamination of the vulva 
and perineum. 

b. A clean delivery room. This implies that the preliminary prepara- 
tion of the patient including the enema, bath, cleaning and shaving of the 
genital region, etc., should be done in a separate room and not in the labor 
or the delivery room. VHien in an emergency a patient must be prepared 
in the deliver j’' room, special pains must be taken to clean it after labor. 
Similar care should be taken after delivery of a patient who has developed 
fever before or during labor. Every person admitted to the delivery room 
should be free from any sldn or throat infection, and covered with a clean 
cap and gown. Admission should be restricted to tliose needed for the 
conduct of labor. 

c. There should be provided in the delivery room sufficient sterile and 
other supplies for use in any noi'mal or pathologic labor. 

d. The delivery room should be in charge of a competent nurse who 
should have enough assistance so that a nurse with good obstetric training 
will always be present at every deliveiy. 

e. There should be one or more internes who have nothing to do with pus 
cases who should be always on call for service in the delivery room. 

f. All doctors and nurses conducting or directly assisting in the de- 
livery of a patient should wear masks, sterile gowns, and gloves. 

g. Rules for the delivery room should be formulated and posted. 

h. As operative interference increases the danger of infection, unneces- 
sary operations should be discouraged, which can be done to some extent 
by requiring the indications for all operations to be given on the patient’s 
history record before the operation. 

As the danger of infection is much increased in serious operations in- 
cluding high forceps, cesarean section, version and manual removal of the 
placenta, and in the serious complications of labor such as antepartum 
hemorrhage, convulsions, postpartum hemorrhage, etc., consultation on 
these cases with members of the obstetric staff or some other recognized ob- 
stetric authority should be required in all cases. 

III. To prevent infection after labor, special attention must be given 
to the cleaning of the genital region and to the wlvar dressings. 

If a patient has a temperature of lOO.I'’ or over, infectious precautions 
should be ordered including tagging the bed, a special bedpan, and any 
nurse earing for her should wear a special gown and gloves. 

If a patient has a fever of 100.4° or over twice on each of two successive 



200 


AMEHICAN JOUKXAE OP OBSTETRICS AND .GYNECOLOGY 


days or a cliill M’itli liigli tcmporatnrc, with symptoms of septicemia or 
pjcmia, slic sliall be isolated fi'om normal piicrperae and cared for by a 
nurse who does not attend afebrile maternity patients, and who observes 
all standard rules lor the care of patients with communicable diseases. 

IV. No operations on patients with incomplete abortion shall be done in 
the delivery room. Abortion eases Avith fever shall not be cared for on the 
maternity service. 

V. All cases of foA’or in puorperium shall be I'cported daily to the super- 
intendent of the liospital and to the staff obstetrician on service, and such 
records .shall be at all times accessible to the hospital inspector. 

VI. All eases requiring isolation as described in Rule III shall be re- 
ported to the Ilealtli Department. 

In tlie control of infection in patients delivered in their homes, reliance 
must be placed chiefly upon reports of severe infections as defined in Rule 
III. The difficulties in securing such repoi’ts might be less than in cases 
of contagious diseases, for no quarantine or placarding of domiciles would 
be nccessaiy. The acquiesecnee of midAvives could be secured institut- 
ing yearly or periodic license, and this could be used to inspect their equip- 
ment and ability. The cooperation of physicians could be facilitated by 
the efforts of medical schools and societies. Fcav operations are uoav done 
in homes. As operative interference is directly or indirectly the most im- 
portant factor in puerperal infection, mortality from this source Avould be 
less in homes than in hospitals. The moral effect of a system of maternal 
supervision Avould alone have considerable influence in home practice. 

I have not dAvolt upon the need of I'educing puerperal infection. This is 
not one of the chief causes of death like tuberculosis, pneiunonia, or can- 
cer. It kills about as many as diphtheria and more than tAvice as many as 
scarlet fcA'cr or typhoid foA'^or. It takes a toll of about 5,000 Avomen a year, 
and these are the mothers, the most important members of the community. 
It also costs much illness and permanent disabilitj’'. Its control is a great 
desire of the Avomen of this country. It led to a crusade of the newly en- 
franchised women Amtei’s in 1920 for the passage of the Maternity and In- 
fancy Welfare Act, the Sheppard-ToAA’ner Bill. It causes them to continue 
action to secure the passage of similar measures to replace that laAV that 
expired in 1929. It is the desire of cveiy physician aaAio has AAutnessed the 
grief and despair of families bereft of mothers lost unnecessarily. 

2333 Clea'eI/And Aa^enije. 


ABSTRACT OB DISCUSSION 

DE. E. D. PLASS, Ioava City, Ia. — There is no doubt of the need for improvement 
in obstetric mortality, but personally I doubt whether much can be accomplished under 
present conditions by any sort of government regulation. The Sheppard-Towner c 
lias elicited such Avidespread disapproval of the governmental interference w i e 
practice of medicine that I am quite convinced that statutes of that sort, mee mg suci 
opposition as they do, can accomplish very little good. Certainly, the experience las 
been that obstetric conditions may be improved much more easily under a sys m 



bacon: puerperal infection 


201 


liospital regulation, where the staff of the hospital interests itself in the character of 
obstetrics done and insists that consultation be called before any of the more serious 
obstetric procedures are carried out. Obmously such regulations are more applicable 
to the larger hospitals, whereas the situation is most serious in the smaller institutions. 
But even in the latter I doubt whether any sort of government regulation can in the 
present state of society be of much use; public opinion must be aroused. 

There is, however, one phase of the problem which can be carried out without too 
great opposition. There is relatively little accurate information concerning the char- 
acter of obstetric practice as a whole. We have statistics from the larger hospitals and 
cities but practically nothing from smaller communities, and we should have composite 
data. I have been attempting to get such figures from the State of Iowa by the inclu- 
sion in the regular birth certificate of a statement from the doctor regarding the char- 
acter of the delivery. While these data have not yet been fully analyzed, some very in- 
teresting statistics have appeared. For example, among 40,000 births scattered 
throughout the State of Iowa, the cesarean incidence has been one per cent. There 
were 400 sections in the 40,000 deliveries. In the communities of over 10,000 popula- 
tion the hospital incidence of cesarean section was 3 per cent, while in the smaller com- 
munity hospitals the cesarean incidence was 3.3 per cent. In home deliveries the inci- 
dence was 0.3 of 1 per cent. As Dr. Bacon has suggested, the hospital admission of pa- 
tients leads the doctor generally to more interference than he would commonly under- 
take, and the relationship between interference and infection has been so thoroughly 
pointed out that it need not he discussed. In the 400 cesarean sections done there were 
32 stillborn children; S per cent of the cesarean sections were done in the presence of 
still births, which indicates nothing wong with the institution itself but rather with the 
training of the doctors who believe that cesarean section is a reasonable procedure for 
the delivery of dead children. 

DB, JAMES K. QUIGLEY, Eochester, N. Y. — ^Dr. Bacon has given us something 
to think about. If the medical profession cannot or will not solve this problem, there is 
no question I believe, as to the authority of the State to attempt to regulate it. The 
program of maternal care as inaugurated under the Sheppard-Torvner law, was not con- 
tinued long enough to prove or disprove its value. To be sure, the emphasis was laid 
upon prenatal care but it at least was edue.ational in pointing out the importance of 
good care at delivery. Of 946 women who received prenatal care in the State Clinics in 
New York in 1931 and were delivered, only one mother died and the cause was placenta 
previa and postpartum iufectiou. Similarly in Westchester County of 1507 women at- 
tending prenatal clinics in the past seven years, there were only 4 fatalities, a rate of 
20.8 per 10,000 or one-third the mortality rate of the entire district in 1931. Another 
feature of this work in New York State was a series of postgraduate lectures to County 
Jledieal Societies. These included the discussion not only of prenatal care, but the 
conduct of labor, normal and pathologic, rvith the emphasis placed upon conservative 
obstetrics. Here I think is a possible method of attack provided it were enlarged upon 
and continued. 

I agree with Dr. Bacon that the embryo physician obtains his real impressions in 
clinical obstetrics more from his attending staff in his internesliip than from his teach- 
ers in medical school and a great responsibility and obligation is that of the staff ob- 
stetrician. Not only by his teaching but by his example will he influence the younger 
man, and how can one expect to make conservative obstetricians of internes who daily 
SCO their teachers employ operative procedures with scant or no indications in a large 
percentage of private patients? Dr. Bacon's recommendation that the small general 
hospital accepting maternity cases and improperly caiing for them should be prohib- 
1 cd from taking maternity cases until it has cleaned house and complied n-itli rules is 
a good one. The general hospital’s responsibility in the present high mortality rate 



202 


AMERICAN' JOURNAL OF OBSTETRICS AND GYNECOLOGY 


has been overemphasized. There are many general hospit.ils with separate obstetric de- 
partments and staffs where as good work is done as in the special lying-in institutions. 

Di. Bacon has formulated a good working plan for hospital inspection, more far- 
reaching than that of tlio American College of Surgeons or the American Medical As- 
sociation, where it seems to me an undue emphasis is placed upon maintenance of rec- 
ords and holding of staff meetings, to the neglect of an .appraisal of the clinical work 
and its results in any institution. 

I endorse emphatically every paragraph of Dr. Bacon’s rules for the conduct of a 
maternity hospital and in addition would include a regulation that all nurses and in- 
ternes be compelled to report anj’ skin infection, no matter how trivial, and any acute 
illness such as cor3’za or sore throat before going on dutj’ in the morning. There have 
been several opidemies of puerperal sepsis dircctlj* traceable to streptococcic sore 
throats. 

DE. ARTH'UE .1. SKEEL, Cleveland, Ohio. — It was mj’ privEegc j'estcrdaj’ to 
show that large general hospitals e.nii do good obstetric work. It seems to me that 
the trouble occurs largel}’ in the .small hospital where obstetrics is done onh- inci- 
dcntallj'. It becomes desirable to do some obstetric work and the hospital allows its 
doctors to do this without giving anj* consideration as to how cases can be handled. 
It niaj" be neccssarj- to use the licensing power of the State to regulate the acceptance 
of such obstetric cases in the hospitals. It occurred to me that there might bo some 
objection on the part of the medical profession to such control, and I think that 
whether this control should bo made b.v the countj-, city, or state government, it would 
bo well for the medical profession to keep their lingers on this control. This would 
do awaj" with much of the fear of governmental regulation of medical practice. 

DE. JAMES F. BALDWIN, Columbus, Onto. — Several years ago, at Grant Hos- 
pital, we thought there were altogether too manj- cesarean sections performed. The 
Obstetrical Staff, therefore, had a meeting and unanimously adopted a rule that no 
one should be permitted to perform a cesarean section, do a high forceps operation, 
a version, or induce labor, without consultation with one of four men, of whom I hap- 
pen to be one. If one of the four has a case, he must consult with one of the others. 
This program has alwaj's worked beautifullj-, and with a marked dimbiution in the 
performance of these operations. We have felt that an obstetrician rvho is tired out 
with long attendance on a case, is not a good judge of the desirability' of operative 
interference, but that a fresh man called into the case would exercise much better 
judgment. 

DE. BACON (closing). — The possible objection of physicians to the establishment 
of a system of inspection, of course, has to be recognized. No health officer would 
undertake anj’ measure of that kind without the support of the medical profession and 
I think the suggestion of Dr. Skeel is most valuable, that these inspectors should be 
nominated by the medical society. If the medical societies and the better element of 
the medical professioji would cooperate with the health department in such inspection 
manj^ of the difficulties that are anticipated would disai)pear. In regard to what 
Dr. Quigley said about the investigation of cases of death bj' the State, that is, of 
course, important but it is a little like locking the door after the horse is stolen. It 
maj- discover the horse, and it may discover how the stealing occurred, but it does not 
save the horse, in this case the motlier. Therefore, the supervision that will prevent 
death is something that should be added. It is only with the cooperation of all of 
the elements of the community, the laj'uian, tlie medical societies, and the state, that 
results can be accomplished. Medical teaching has not succeeded completely in the 
past and we must remember that the great majority of pliysicians graduated years 
before the better teaching was in vogue and their work needs special control. 



A STUDY IN CORRELATION OP THE SEIHMENTAJHQNJTEST, 
FILAMENTl-NO NFILA MENT, AND THE WHITE 
^ " CELL COUNT IN'GYNECOLOGY* 

H. Wellington Yates, M.D., David M. Davido'w, M.D., 
Elizabeth Putnam, and Pkances Ellman, 

Detroit, Mich. 

A ny movement to determine the inf ectiotisness of a given case is quite 
worth while. Since we have so often been misled by the clinical 
findings as to the acuteness of disease, the profession at large has depend- 
ed more and more on the white cell count ; it is with this thought in view 
that we present the following : 

The sedimentation test in gynecology has been the subject of consider- 
able discussion during recent years ivitli conflicting reports for and 
against its value in the diagnosis of pehde conditions. Since a considerable 
amount of material was at our disposal, it was decided to carry on this 
test routinelj^ on all eases admitted to the Gjmecological Service at Re- 
ceiving Hospital, Deti-oit, for a period of one year and to correlate the 
results on the patients operated upon for that period. During that time 
(1929 to 1930) very little or no attention was paid to the test as a diag- 
nostic aid or as an aid in prognosis. It was our aim to settle definitely 
in the minds of our staff the value of the sedimentation test in gynecology. 
All the operated cases were reviewed at the end of 1930 and the sedimenta- 
tion rates cheeked with the pathologic diagnoses and the average rates 
for the various conditions noted. This study had been undertaken previ- 
ously^ two or three different times udthout any conclusive results. The 
reason for this was due apparently to the fact that inexperienced tech- 
nicians, i. e., students and internes, carried on the ivork and the results 
were not at all uniform. During this particular study only experienced 
laboratory teehnieians have done the work and the technic has not varied, 
as a result the tests have been quite consistent with the clinical findings 
so that fairly definite conclusions could be drawn. 

Since that probationary period of one year, the test has been used 
routinely and in order to bring it up to date, the operated cases for the 
past two years have been added to the first table. In addition, during 
the past few months, we have used routinely the filament-nonfilament 
count as developed in its simpler manner by Faidey, St. Clair, and 
Reisingor. to check this new laboratory test with that of the sedimentation 
and uhitc cell count. AYe hope to present here our findings in relation 
to these various tests and to determine which one is the most sensitive 
and valuable adjunct to the gynecologist’s armamentarium. 




203 



204 a:mekican journal op obstetrics and gynecology 

The settling out of the red blood cells from the serum is not a recently 
discovered phenomenon; Galen observed this reaction almost two thou- 
sand years ago. John Hunter also made this observation in the latter 
part of the Bighteentli Century, and he also described the variation in 
sedimentation rates in different sjiecies of animals. Various investiga- 
tors from time to time reported the same observations, but did not corre- 
late their results clinicall 3 L Pahracus, in 1907, was the first to note the 
variation in sedimentation rate which occurred in pregnancy, infectious 
states, and in different periods of the same disease ; his work Avas ampli- 
fied by Linzenmeier who particularlj’ placed the value of the test in the 
field of gynecology. 

The exact biochemical cliangcs which account for the A’ariation in 
sedimentation rate of the red cells, are still nnlinown, but there are a 
number of theories advanced for this phenomenon. The most commonly 
accepted one is based upon the number of negative charges carried by 
the er.ythroeytes ; as the negative charges arc taken off, cither by posi- 
tiveh' charged agglut inins present in the blood, or by the globulins whose 
presence increases the viscosity and decreases the negathm charges, the 
red cells no longer repel each other and tend toward an increased rouleau 
formation. The more marked is this rouleau formation, the shorter is 
the time that it takes for the cells to settle out. 

In our clinic, a definite routine Avas carried out for all patients. Every 
patient had a sedimentation test on admission in conjunction Avith other 
laboratory Avork. In addition all blood counts Avere accompanied bj’’ 
sedimentation tests Avhich meant that all operated cases had this test 
twenty-four to fortA*-cight hours prior to operation. During the studj' 
of the filament-nonfilanient count, this additional information has been 
added to the patient’s record and the old type of differential count has 
often been dispensed with. The operatiA-e cases Avere chosen by the staff 
on the basis of the folIoAving requisites : 

1. History. 

2. Pelvic findings throxigh bimanual and speculum examinations. 

3. Absence of elevated temperature, except in cases of culdesac .abscesses. 

4. White blood cell count of 10,000 or less with a corresponding differential count, 
except in cases of pelvic abscesses. 

5. Absence of complicating factors; such as hidney pathology, heart lesions, 
respiratory irrfections, etc., except Avhere such complicating factors were compensated 
for and operative procedure indicated. 

No attention was paid to the sedimentation rate for the first year, it 
being desired to continue the routine on tlie service, then later to check 
back and correlate the operatiAm and pathologic findings Avith the sedi- 
mentation rate and clinical diagnosis. In this manner Ave sought to com- 
pare these Amrious final diagnoses and sedimentation findings to detei- 
mine the value of the relationship between the tAVO. This fii’st study em- 
braced a series of 545 operative eases Avith a corresponding group of 1450 



YATES, ET AL. : SEDIMENTATION TEST 


205 


sedimentation tests. The operative procedure may be tabulated as 


follows ; 

A. Abdominal operations 

1. Pelvic inflammatory disease 

2. Fibroids 

3. Miscellaneous laparotomies 

4. Appendectomies 

5. Ectopics 

B. Cervical operations 

C. Perineal operations 

D. DDatation and curettage 

E. Bartholinectomies 
E. Colpotomies 

G. Examination under anesthesia ■without operation 


220 

101 

30 

19 

r* 


377 


51 
40 

52 
10 

7 

8 


The revised group of cases which brings the series up to August 1 of 
this year and includes the first year’s group upon which the results were 
first noted, may be listed as f ollow's : 


A. Abdominal operations Total 1156 

1. Pelvic inflammatory disease 633 

2. Fibroids 341 

3. Miscellaneous laparotomies 83 

4. Appendectomies 56 

5. Ectopic pregnancies 43 

B. Cervical operations 136 

C. Perineal operations 115 

D. Dilatation and curettage 216 

E. Bartholinectomies 23 

F. Colpotomies 83 

G. Examination under anesthesia 44 


Total 1773 


The total number of sedimentation rates during this three-year period 
is approximately 6,000. 

The cases operated for pelvic inflammatory disease included all types 
and stages of salpingitis, with and without ovarian disease. The majority 
of these cases were varieties of chronic salpingitis with gross palpable 
pehuc pathology. A feiv cases of acute salpingitis were found at opera- 
tion. It is never our custom to operate in acute cases, therefore, these 
may be classed as errors in diagnosis. In these few instances the sedi- 
mentation rate corresponded with the findings of acute infection. 

In our clinic about 60 per cent of the cases came from the colored race 
and most of the fibromyomas were found in these people. As is true in 
other clinics, 80 to 85 per cent of these women also had pathologic adnexa, 
which frequently necessitated the removal of both ovaries, although 
ovarian tissue was conserved wherever possible. The fibroids showed 
10 to 15 per cent of various degenerative changes, and depending upon 
the extent of degeneration, the sedimentation rate corresponded fairly 
well with the pathologic findings. 

In the miscellaneous laparotomies wdiich included ovarian cysts, ex- 
ploratory, uterine suspensions, freeing of a^esions, etc., the majority 
of these cases were opened in addition to perineal work done preceding 
the laparotomy. 



206 


AMERICAN JOURNAIj OP OBSTETRICS AND GYNECOLOGY 


Appendoetoinie.s -were done on eases mistakenly diagnosed as having 
adnexal disease. ’ 

The ectopic pregnancies revealed 31 ruptured vith free blood in the ab- 
dominal cavit.v. Six were diagnosed clinically as tuboovarian abscess, al- 
though Die sedimentation rate ivas higher tlian nsuallj" found in that type 
of pathology, riiere ivere 12 cases found to be old ruptured ectopics at the 
time of operation, this group included the 6 diagnosed as tuboovarian 
abscess. 

The grouj5 of cervical operations included 24 advanced cases of cervical 
carcinoma, of ■which 7 were treated with radium. There were 12 eases of 
cervical polyp and the remainder consisted of various stages of cervicitis 
and cndocervicitis, these were ti’catcd by cauterization, trachelorrhaphy, 
low amputation or Sturmdorf operation. 

The perineal operations were for the most part anterior and posterior 
colporrhaphy and pcrineorrliaphy ; there were also 11 patients who had a 
\Yatkins interposition operation and 5 patients who had extensive condy- 
lomata acumina removed bj' cautery. 

Among curettages, there were 91 done for diagnostic purposes; 15 for 
potj^poid endometritis, and 110 for retained secundines. Tlie large num- 
ber done for retained secundines is due to the fact that during the past 
eighteen months, only acute cases have been admitted to the hospital and 
the largest proportion of those cases have been incomplete abortions with 
bleeding. 

Thei’C were 72 eases of frank culdcsac abscesses diagnosed and operated 
upon as such. These wore the only patients in the series who had elevated 
temperatures and white blood cell counts over 10,000. Eleven cases diag- 
nosed as pelvic abscess had colpotomies done but instead of pus, 2 were 
found to be old ectopics, and 9 irere cases of chronic salpingitis with large 
hydrosalpinx. In all these patients the sedimentation rate was over thirty 
minutes. 

In 44 eases made ready for operation, when taken to the operating room 
for examination under anesthesia, Avhere the clinical diagnosis was in 
doubt, were not operated upon because of lack of pelvic pathology. It 
was interesting to note that in every one of these cases the sedimentation 
rate was over sixty minutes. 

The pathologic and clinical diagnoses of the cases operated upon quite 
often did not agree, and it was in these especially where a cheek up on the 
sedimentation rate which had been done before operation proved very 
illuminating. The average sedimentation rates as noted in the various 
types of pelvic pathology in this series are listed in a subsequent table. 

It is not to be understood that these figures are exact for each condition, 
nor are they intended to be pathognomonic. On the contrary thej’' are 
only average figures and the margin of variation between the rates for 
the various pathologic types is not verj'’ exact. The sedimentation rate 



207 


YATES, ET AE. : SEDIMENTATION TEST 


is only an additional aid in the general picture when making a diagnosis 
and not a short cut or an easy method toward exactness. 

We consider the sedimentation rate of two hours or over as normal. The 
average rates for the A^arious conditions are as f oIIoaa'S ; 


Culdesac abscesses 
Acute salpingitis 
Pyosalpingitis 
Subacute salpingitis 
Chronic salpingitis 
Healed salpingitis 
Fibroid uterus 

Appendicitis subacute and elironie 

EndoeerA’icitis and cervicitis 

Ovarian cyst 

Eetained secundines 

Advanced carcinoma 

Bartholinitis 

Ectopic pregnancy 

Cervical polyp 

Polypoid endometrium 

Perineal lacerations 

Normal 


4 to 10 min. 
10 to 20 min. 
10 to 20 min. 

20 to 35 min. 
35 to 60 min. 
60 min. plus 
59 min. plus 
79 min. plus 

100 min. plus 
122 min. plus 
41 min. 

21 min. 

90 min. plus 
40 to 50 min. 
120 min. plus 
83 min. 

120 min. plus 
120 min. plus 


It has been interesting to note in our series that in cases of incomplete 
abortion Avith definite anemia, the sedimentation rate is more rapid than 
normal and this finding corresponds AA'ith that of other observers. This 
anemic condition may also explain the loAA'ered sedimentation rate in rup- 
tured ectopic pregnancies. 

Of the 1773 cases studied, 1620 showed a definite correlation hetAveen 
the pathologic diagnosis and sedimentation rate. This AA'ould give the test 
an approximate accuracy of about 91.4 per cent. We believe that these 
figures compare favorably Avith any laboratory test at our disposal. As 
compared to this, 1202 cases shoAved a definite correlation between the 
AA'hite blood count and pathologic diagnosis ; this means a percentage of 
67.8 per cent accuracy as compared with the sedimentation rate of 91.4 per 
cent. 

There is another laboratory procedure AA'hich has attracted considerable 
attention during the past tv'o or three years Aidiich promises, according to 
some inA-cstigators, to surpass the sedimentation test in usefulness. This 
is knoAvn as the filameut-nonfilament differential blood count. 


Avnetb, in 1904, was tlio first to demonstrate the clinical significance of tlie various 
forms of nuclei in the pob'morphonuclear neutrophils during A^arious types of infec- 
tions. He separated tliese neutrophils into five classes, depending upon the segmenta- 
tion of their nuclei. In Class 1 he placed the cells with slightly dented nucleus. This 
made up about 5 per cent of the total in normal indmduals. Gass 2 cells had two 
lobules to the nucleus, and comprised 35 per cent of the total. Class 3 had three lobules 
and tot.alcd 41 per cent; Class 4 made up 17 per cent of the total and had four lobules, 
Avhile Class 5, Avhich made up the balance of 2 per cent had five or more segmentations. 
The number of segmentations determined the age of the cell; the greater the number of 
segmentations, the older the cell. His AA’ork, aa’IiUc A-ery complete, prOA’ed too compli- 
cated for ordinary routine differential counts, but it laid the foundation for the investi- 
gation Avhich folloAved. He proved that an increase in the number of immature cells 



208 


AMERICAN JOURNAL OP OBSTETRICS AND OXNECOhOGY 


represented the response of the myeloid tissue to t!ie stiinulation of any infections agent, 
and tliis he termed "the shift to the left.’’ As the infection subsided, the xmmher of 
iininotvrc cells returned to nonti.-tl and this phcnomcnojv he termed "the shift to the 
riglit." 

Since Arncth's work, there have been efforts xnadc to simplify tlie nuinbcr of classes; 
to make the test more applicable to clinical use. Schilling, in 1P20, published a modifi- 
cation of Arneth 's grouping, and placed more emphasis on tlm change in the staining 
characteristic of the granules as a result of toxic stimulation and change in size of the 
cytoplasmic granules. 

In 1924, Pour and Kruinboor contributed another plan of differentiation in order to 
simplify former methods. In 1927, Cook and Ponder made valuable contributions to 
this study of neutrophils. Pinally, in 1930, Farley, St. Clair, and Eeisinger developed 
what seems to be a very simple method. They regrouped the five classes of Cook and 
Ponder into two classes; the first being the same as Class 1 and the second including the 
other four classes; they termed the first class as "nonfilameut" and the second group 
as "filaments.” 

Farley, ct al., adopted as normal a nonfilamcut count of S to 16 per cent and this is 
practical!}' agreed to by other observers. The normal of small lynjphocytes was placed 
at 25 to 30 per cent. 

Weiss pointed out that during infections every cellular system of ttie body is called 
into action. The bone marrow which supplies the polymorphonuclear neutrophils re- 
sponds first; and depending upon the severity of the infection, depends the number of 
nonfilamont ceils which the marrow contributes. In very acute and severe infections 
the number of noiifilument cells may be markedly increased. During this time, the 
eosinophils arc usually absent, as arc the monocytes, and the lymphocytes have de- 
creased at times to 10 yicr cent. When the infection subsides the reticuloendothelial 
system comes into action to replace the neutrophilic stage. The noufilament cells de- 
crease and there is a definite increase in monocytes with increased nuinhers of lympho- 
cytes as the lymphatic system becomes active. Tims one should bo able to determine 
and visualize the course of an infection by repeated counts of this type and prognosis 
could be gauged by the increase or decrease of lymphocytes. 

We became interested in tliis test because of some work done by ReNeno 
and Berent of Detroit and since May, 1932 have been using it routinely on 
our service. Herein arc grouped 538 cases which fall into the following 
classifications : 


Infectious 

S3S 

Abortions 

167 

Miscellaneous 

96 

Residual 

43 

Total 

638 


In the tabulation of the subheadings of these groups, the average blood 
count and sedimentation rate, in addition to the filament-nonfilament 
count has been recorded. The percentage of aecnracy’’ lias been determined 
bi' comparing the three laboratory methods with tire pathologic and clin- 
ical diagnoses and actually enumerating the number of eases wherein 
there seems to he no connection between laboratory test and diagnosis. 

COMMENTS 

There -was a definite correlation of sedimentation rate and filament-non- 
filament count in the cases of infection. Tliis was especially true in the 



YATES, ET AL. : SEDIMENTATION TEST 


209 


acute and subacute eases where tJie tests fairly paralleled each other. The 
cases of acute exacerbation showed that the sedimentation rate was more 
accurate in demonstrating the infection than was the filament-nonfilament 
count. The same situation was found in the study of the pelvic abscesses. 

I. Infections 



oases 

SEDIMENTATION 

FILAMENT 

NONFILAMENT 

BLOOD COUNT 

Acute salpingitis 

59 

10-20 

36-69 

10-58 

17,000 

Subacute salpingitis 
Clironic salpingitis 

28 

20-35 

40-70 

15-32 

11,000 

40 

35-60 

50-70 

10-26 

9,800 

Acute exacerbations 

42 

12-25 

50-78 

8-22 

12,500 

Pelvic abscess 

14 

6-14 

34-65 

10-34 

16,000 

Tuboovarian abscess 

26 

7-20 

44-71 

10-38 

13,000 

Hydrosalpinx 

Fibroid and 

9 

S-120 

52-66 

3-12 

7,200 

pelvic cellulitis 

14 

20-48 

44-70 

4-26 

7,800 


II. MlSOELUANEOnS 



OASES 

sedimentation 

FILAMENT 

nonfilament 

BLOOD COUNT 

Fibroids 

34 

45-120 

40-74 

6-20 

, 8,100 

Ectopics 

16 

22-72 

43-71 

5-24 

9,200 

Bartholin abscess 

4 

20-25 

50-60 

12-16 

6,400 

Tu-isted ovarian cyst 

3 

26 

55-57 

22-23 

11,400 

Appendicitis 

Uterine polyps with 

6 

77-90 

44-54 

10-28 

7,550 

infection 

7 

13-22 

53-64 

10-30 

12,600 

Pregnancy 

6 

60-90 

58-62 

4-14 

6,800 

Perineal cases 

14 

80-120 

54-70 

5-15 

8,000 

Carcinoma of cervix 

6 

22-30 

49-55 

11-35 

10,500 


III. ABORTIONS 



CASES 

SEDIMENTATION 

FILAMENT 

NONFILAMENT 

BLOOD COUNT 

Abortion 

83 

21-120 

38-70 

4-54 

5,000-19,600 

18,600 

13,500 

8,750 

Septic abortion 

34 

7-31 

45-60 

10-45 

Abortion with anemia 

36 

19-48 

43-70 

14-36 

Threatened abortion 

14 

34-120 

46-75 

9-16 



IV. KESIDUAI, 

CASES 




CASES 

SEDIMENTATION 

FILiVMENT 

NONFILAMENT 

BLOOD COUNT 


Cyst of Gaertner 's 


duct 1 

Pyelitis 4 

Jloningitis 1 

Ulcer of vagina 1 

Ecctovaginal fistula 3 

Suljinvoluted uterus 2 

Ovarian cysts 2 

Fibroid ivith 
pregnancy 1 

No pathology 2S 


120 

66 

14 

30-60 

48-64 

14-28 

32 

50 

31 

21 

48 

32 

22-40 

40-53 

7-16 

60 plus 

64 

12 

90 

50 

10 

60 

54 

12 

00-120 

49-71 

5-16 


4,800 

15,400 

22,100 

15,800 

8,500 

7,600 

0,100 

7,300 

7,450 




210 


AJtBnrCAN JOURKAB OP OBSTETRICS AND GYNECOLOGY 


The ^vllite blood count vai-icd considerably and ivas quite frequently not in 
accord witb the pathologic and clinical diagnosis. The filarnent-nonfila- 
nient count apparently A^aried as to the severity of the infection present, 
and it was noted that patients with poor re.sistance had Ioav nonfilament 
counts. This may account for the relatir^ely low nonfilament count in the 
protracted cases of euldesac abscess. 

The total of nonfilament cells returned to normal more rapidly than the 
sedimentation rate did after operation or subsidence of the infection and 
in tliis way proved to be a A'cry definite aid in prognosis of the ease, where- 
as the sedimentation rate took a longer time in showing improvement of 
the patient’s condition and could not be used for progno.stieation. 

As previously noted, inireiy from a diagnostic point of view, the sedi- 
mentation rate shoivod an accuracy of 91.4 per cent. The Avhite blood 
count had an accuracy of 07. S per cent and of the 538 cases tabulated, 415 
demonstrated the accuracy of the filament-nonfilament count, a percentage 
of 77.2. 

The miscellaneous groups again brought out the definite correlation be- 
tween the sedimentation rate and filament-nonfilament count. Here, too, 
the white, cell count is shown to be a negligible factor. The lowered sedi- 
mentation rate in the ectopic pregnancies may be due to the anemia re- 
sulting from hemorrhage within tlie abdomen, for the lowest rates ivere 
found in the cases with the greatest hemorrhage. The sedimentation test 
was rapid in cases of Bartholin abscesses, while the filament-nonfilament 
count, for some unknown reason, Avas normal. In cases of appendicitis, 
the rcA'crsc situation Avas true. These are findings for Avhich Ave could find 
no definite explanation. All the cases of uterine polyps Avere infected as 
Avere the cervical carcinomas and shoAved the proper response on the part 
of the tivo tests. 

In the group of abortions occurred the most bizarre Avliite blood counts, 
sedimentation rates, and filament counts. The cases of septic abortion 
shoAved rapid sedimentation and increased nonfilament cells as did the 
severe anemias folloAAung abortions. The cases of abortion, both complete 
and incomplete, without infection had no correlation Avhatever betu'een 
the tests or Avith the condition present. This may be due to the fact that 
the sudden change in the blood picture brought about by rapid loss of 
blood, threiA'’ tlie hemopoietic system into such marked actiAuty that all the 
blood forming tissues Avere throwing cells into the blood stream. The same 
condition existed in cases of threatened abortion Avith acute onset of bleed- 
ing AA'hich later stopjAed and AAdiere expvilsion of fetal structures did not 
occur. 

The group of residual cases is self-explanatory and corresponds ndth the 
findings preAuously noted. 

Our conclusions are as f oUoavs : 

1, (A) The percentage of accuracy of Avhite blood count in these two 
studies was 67.8 per cent. (B ) That of the filament-nonfilament count Avas 



YATES, ET AE. ; SEDIMENTATION TEST 


211 


77.2 per cent. (C) The accuracy of the sedimentation rate was 91.4 per 

cent. _ 

2. There was a definite correlation of the sedimentation rate and tda- 

ment-nonfilament count in the infectious conditions. 

3. The white blood count was not dependable. 

4. In our cases of marked anemia the sedimentation rate was more rapid 
than normal. 

5. In the cases of abortion with bleeding there was no correlation be- 
tween the three tests. 

1551 Woodward Avenue. 

ABSTEACT OF DISCUSSION 

DE. HARRY E. HUSTON, Dayton, Onio.—Duving the past two years we have con- 
ducted an investigation at the Miami Valley Hospital for the purpose of determining 
the value of the erythrocyte sedimentation test and the modified Schilling fi.lament-non- 
filament polymorphonuclear leucocyte count in surgical diseases. We have found a 
combination of these two simple laboratory procedures to be of the greatest possible 
diagnostic and prognostic value, when intelligently combined with the clinical signs and 
symptoms. The teclmic of the tests is exceedingly simple and is not time-consuming. 

We have found the test to be of particular importance in pelvic inflammatory disease 
and in acute suppurative abdominal conditions. The filament-nonfilament leucocyte 
count provides an accurate index of the response of the myelopoietic system to existing 
inflammation or hemorrhage. The degree of myelopoietic response conforms to the 
severity of the stimulus, as measured by the appearance of increased numbers of im- 
mature pob'morphonuelcar leucocytes in the peripheral blood stream. In many in- 
stances the ordinary white blood cell count, which does not distinguish between mature 
and immature polymorphonuclear neutrophils, not only fails to yield tlie desired in- 
formation, but not infrequently leads to diagnostic confusion. This is particularly true 
in acute suppurative abdominal disease, in which the total white blood cell count falls 
udthin the normal limits or shows but a slight increase. In such cases also the total per- 
centage of polymorphonuclear leucocytes may not be api^reciably increased. If it is 
found, hon-ever, that the percentage of immature nonliinment polymorphonuclear neu- 
trophils is appreciably increased, this single additional observation assumes the great- 
est possible importance. In many instances, we have encountered cases of acute ap- 
pendicitis in which neither the clinical signs nor the ordinary white blood cell count 
provided convincing diagnostic evidonee, but in which the percentage of immature 
polymorphonuclear leucocytes was well above the normal level. This finding is of par- 
ticular importance if repeated blood counts arc carried out and the number of immature 
cells shows a progressive increase. Such evidence indicates that suppuration is present. 

In the differential diagnosis of uncomplicated benign pelvic neoplasms and pelvic 
inflammatory disease the information provided by these tests has been invariably con- 
clusive in our experience. 

DR. DAVIRENCE I'l. RAND ALE, Rochester, ]Minn. — Dr, Yates ^ paper serves to 
emphasize further the importance of the correlation Iretween the clinical and laboratory 
fh-Jl.-j. This is brought out in the paper by the statement that 91 per cent of his sedi- 
mentation tests were accurate when the history and clinical findings were taken into 
consideration. If one employs this test as a short-cut to diagnosis it is likely to get us 
into trouble. 

It lia.s been pointed out by Westergren that the sedimentation test is really a test of 
the .sedimentation reaction of the individual; that it is nonspecific and is not neces- 
■sarily a help to us in localizing the disease process. We have felt that the sedimenta- 



212 


a:merican- journal op obstetrics anb gynecologt 


tion reaction in conjunction with tlie oll.cr data obtainable concerning the patient will 
allovr ns to make a final diagnosis in the first place, and in the second place, after the 
reaction is determiimd repeatedly on the same patient, it permits us to judge results in 
treatment and to aid in determining the time for operative interference. 

UJl. ALBER'T JIATHIEL, Portland, Oregon. — After a consideration of between 
eighteen and twenty tliousand estimations of the rate of sedimentation of red blood 
cells, we h.ave arrived at the following conclusions : 

1. The sedimentation r.ate is incrc.ased in the blood of patients who have in their 
bodies conditions of acute infl.ammation, marked cellular proliferation, or hemorrhage 
under pressure. 

2. Lobar pneumonia and acute miliary tuberculosis give the highest rates followed 
closely by acute gonorrheal salpingitis. 

3. Infection is not ncccssarj’ to a rapid rate as carcinoma and pregn.ancy both cause 
it to be increased. 

4. A routine red cell sedimentation rate in conjunction with every physical examina- 
tion will repay the gynecologist or obstetrician who of neccssit}’ is not as complete in 
his general examination as the internist. Often the sedimentation rate will be increased 
without any explainable cause and this increase in rate is the warning that some hidden 
trouble must bo sought. In our experience, the sedimentation rate has been of far 
more value than tlio leucocyte count because at times even though there was no leu- 
cocj'tosis and the patient's complaints were more or less vague, the sedimentation rate 
acted as an unmistakable sign that we were overlooking something. 

One such instance I will mention as an illustration, giving only the barest details. A 
woman three months pregnant, normal in every way as far as could be determined and 
w’ith absolutely no complaint except pregnancy, gave an c.vtremely rapid sedimentation 
rate: 50/90. Her urine and leucocyte counts rverc constantly negative and normal re- 
spectively but repeated sedimentation rates were increasingly rapid. After search and 
study a pyelonephritis with nephrolithiasis was found. Had it not been for attention 
to the sedimentation rate this would have been missed because it presented absolutely 
no sjTnptoms. 

DB. FBEDEBICK II. FALLS, Chicago, III.— We liave been studying the sedi- 
mentation test at the Unii’crsity of Illinois from a different angle. We did careful 
tests on a series of 208 gynecologic cases of vaidons types. We then prepared these pa- 
tients for operation according to the usual method of observing the clinical condition 
of the patient. When the temperature remained normal for a week or ten days and the 
leucocyte count was below 10,000, we operated whether or not operation was contrain- 
dicated according to the sedimentation test. After operation we checked the sedimenta- 
tion rate against the number of liospital days and postoperative morbidity and mor- 
tality. There was no appreciable difference in these respects between cases with high 
or low sedimentation rates. Wo feel therefore that a great deal of time ivill be sa^ed 
to the patient if a rapid sedimentation rate be disregarded when it does not agree with 
the clinical findings. 

DB. YATES, (Closing).— All I wish to say in conclusion is that from our experience 
of 1700 cases the sedimentatiou time and nonfilament estimation are of verj definite 
prognostic and diagnostic significance, and we have become more and more skeptical 
about the simple, old fashioned white blood count. As I said in the paper, this is not a 
short-cut to diagnosis, but it is a distinct aid in the study of infectious processes and a 
prognostic guide. I do not wish to put this as an ultimatum in the way of determining 
our position in a given case but, with Dr. Falls, I certainly agree that as clinicians we 
must think cbnically of a patient irrespective of any type of instruments of precision or 
laboratory findings. We find more and more as we study our clinical symptoms that 
after all the basis of our activity should be determined by them. 



THE RELATIONSHIP BETWEEN ^OGENOUS THROAT^^ 
ST REPTOCOCC I ANP^PHERPERAL/I NPECTl^ NS^' 

Foster S. Kellogg, M.D., and Arthur T. Hertig, jMD., 

Boston, Mass. 

(From Departments of Ohstetrics and Pathology, Harvard Medical School) 

D uring the “respiratory season” in 1911-1912, a very severe and 
disastrous epidemic of puerperal sepsis occurred in a hospital in 
Boston. The most strUcing single fact of this epidemic was that a certain 
number of the eases, fatal as well as nonfatal, and regardless of whether 
examined at or near delivery, occurred late in the puerperium.. Some 
were as late as the ninth, tenth, and eleventh day, while occasional patients 
were up and ready for discharge. This epidemic was competently writ- 
ten up and was considered to be primai'ily throat borne. Permission to 
publish was withheld because, one presumes, of undesired publicity. That 
such was the case seems in retrospect a great pity and a great responsi- 
bility as one contemplates the possible educational results of such a pub- 
lished study toward the reduction of puerperal mortality in the past 
twenty years. 

In contrast, in 1927 when a serious outbreak of puerperal infection 
took place at the Sloane Hospital in New York, Meleny and Stevens 
made a careful investigation, with the result that they “failed to reveal 
any probable cause except air contamination (i. e. contact contamination 
through the air, by nasopharyngeal droplets) by carriers among the 
medical and nursing personnel and as a result they recommended the 
wearing of masks by all who enter the delivery room in hospitals.” 

To show that this final sentence is right as far as it goes but does not 
go as far as it should is the purpose of this paper. 

On the evening of December 17, 1931, one of us (P, S. K.) was asked 
to see a patient in consultation in a well-equipped general hospital with 
a small maternity wing. An epidemic of puerperal sepsis was found; 
one patient had died the day before and one was dying. Of ten women 
consecirtively delivered from November 19, 1931, to December 7, 1931, 
nine ran febrile temperatures to a greater or less extent in the puerpe- 
rium. Two of these died and positive cultures of hemolytic streptococci 
were obtained from the blood stream and uterine cavity. Without reiter- 
ating what may be readily seen on the charts, four facts are noteworthy : 
(1) On tlie whole the teinperattn-e rises are later than one expects in in- 
fejjtion at delivery. (2) Several different men delivered the patients. 
(3) Tlie symptoms were largely peritoneal. (4) The prostration was on 
the whole out of proportion to the elevations shonm. 




213 



214 


AJlEniCAN JOUUNAIj OF OBSTETRICS AND GYNECOLOGY 


Having seen the patient in question in consultation (No. 7) and given 
a good prognosis on the basis that she seemed to he localizing in the left 
vault, we disenssed the situation. It Avas agreed to keej) the v'ard shut 
which had been closed since December 5, send snch patients to their homes 
as would probably not need transfusion or surgery, and place such pa- 
tients as remained in a large available open wai’d Avith the AA'indoAvs open 
and shut off from the rest of the hospital. A guess Avas made that dili- 
gent search Avould reveal a throat carrier. 

j\Iuch admiration for the honest manner in Avhich the staff Avas meeting 
its responsibilities has increased Avith their readiness to permit this report. 
It is more impressive in contrast to previous experience. 

Taa'o days later information Avas forwarded that a culture of hemolytic 
streptococci had been obtained from the throat of a nurse in contact AAoth 
all the patients. 

Excerpts from a final letter from llie ph.A^sician in charge shoAV the 
chronological relationship of this contact and are here quoted. “The 
nurse Avas on duty at night in the maternity Avard. Due to the fact that 
it is a small unit there is only one nurse on at night except AAdien deliveries 
occur. Therefore she came in contact Avith every patient in the AA'ard 
except tAvo that had specials. This nurse Avas complaining of sore throat 
and slight malaise about November 25. Tin's nurse Avas admitted sick 
to the medical service November 27 and aa’bs off duty for three days com- 
ing back on the thirtieth. Her throat AA'as cultured but unfortunately 
through some oversight the report came back ‘Negative for diphtheria.’ 
She AAms most unfortunately sent back to the maternity Avai'd.” 

Briefly summarized in the letter the course and end-results AA'-ere as 
folloAVS : 

5 Patients had a rather mild course and Avent home avcII. 

2 Patients died. 

1 Patient sent Iiomo Avith temperature, bled, returned, transfused, Avell. 

1 Patient ran a septic temperature for a long time, A\’as sent home and an abscess 
opened OA’cr Poupart’s ligament on left. Is aa'cII uoav. 

1 Patient ran a septic course, went home after six davs of normal temperature on 
December 25, 1931. She remained tcmpcratui'c free until March 25, 1932, and at 
that time AA’as running a temperature of 102°-103'’ P. Avith intestinal symptoms, 
AA’hether due to the old infection or to grippe Avas not then determined. This patient 
reeoA’ered after six Aveehs AA'ithout definite diagnosis. 

Thus Ave liaAm in this small epidemic a 90 per cent morbidity, lialf mild, 
half seAmre, and a death rate of about 20 per cent. 

The letter continues, “As I told you the idea of streptococcus did not enter my 
head until after closing the AA’ard. On December 7, before any of the patients had 
become dangerously sick, Mrs. Z. dcA'Cloped a scarlet rash. She had had scailet for or 
a few years before. On this day the local board of health was called in but agreed 
Avith a diagnosis of grippe and offered nothing in the Avay of help. 

‘ ‘ There Avere two blood cultures positiA'e for hemolytic streptococcus and a similar 
organism was obtained from the inside of each of these patients uterus. Both le 
The throat cultures were several times negative on all the patients that had le 



KELLOGG AND HERTIG : PUERPERAL INFECTIONS 


215 


disease, including the two that died. About December 15 the State Board of Health 
was called in. Cultures were made from the air with Petri dishes which were nega- 
tive, and throat cultures from the nurses, doctors, attendants, etc., were taken. All 
were negative except this one night nurse. They were negative three days later.” 

So is rotiTided out a clear cut picture sliowing possible results of throat 
borne hemolytic streptococci to parturient tvomcn in a well regulated 
hospital. It demonstrates that hospital sepsis is not a thing of the past 
entirely, and that our technic for the protection of our patients needs 
improvement. 

The explanation of the source of this catastrophe is clinically satisfac- 
tory, but from a bacteriologic point of view leaves something to be desired. 
^Ve are able to supply this additional data in part from another experience 
occurring within three months of the above, in an institution for which 
one of us (F. S. K.) is responsible. It was cheeked by complete bacterio- 
logic studies by one of us (A. T. H.) in a precisely similar single instance 
occurring in still another hospital at about this time. 

Our second experience came from two patients delivered at the Flor- 
ence Crittenton Hospital in Boston. 

A summary of these cases is as follows ; 

Case 1. — Primipara. Low Forceps. Death on the tenth day, postpartum after late 
transfer to Boston City Hospital and "Terminal transfusion.” 

Diagnosis: Streptococcus septicemia (puerperal). Probable peritonitis. 

Case 2. — Primipara. Pace presentation, internal podalic version, Becovery on 
fifty-seventh day, postpartum after early transfer to Boston Lying-In Hospital 
(sixty hours) and early repeated transfusion. 

Diagnosis; Streptococcus septicemia (puei-peral) . 

Knowledge of the death of the first patient came to the chief of the 
Florence Crittenton staff through accidental information from a member 
of the City Hospital surgical staff. This fact goes to show that even 
now the potential seriousness of a single case of puerperal sepsis to other 
patients in an institution supposed to be “well regulated’’ is not appre- 
ciated by otherwise well trained doctors and nurses. Early the following 
morning at the hospital it was rather casually mentioned that “another 
patient had a temperature” the night before. This patient had a tem- 
perature of 104° and a pulse of 130 in the morning and was the picture 
of a full-blown puerperal streptococcus sepsis. Immediately permission 
was asked and granted to transfer the patient to the Boston Lying-In 
Hospital. This transfer was immediately made. At the risk of seeming 
trite such a transfer accomplishes the following objects : (1) It rids the 
small institution with its untrained pupil nurses and poor isolation facili- 
ties of a menace to the other patients. (2) It puts the patient into an 
institution where proper isolation facilities and nursing personnel (i. e. 
septic floor both ward and single rooms with special nurses) are safe- 
guards to the rest of the institution, (3) It places the patient in a posi- 
tion to have constant medical attention, bacteriologic study, and high 
gi'ade nursing. In this connection we believe that, aside from good nurs- 



216 


A5IERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


ing, fresli air, and assured rest (a matter of supreme importance, often 
neglected), frequent transfusion, cheeked by red counts every other day, 
is our only therapeutic measure. We further believe that such trans- 
fusions should he begun very early in the disease and not used as a late 
or last resort. This implies available donors in quantity and a large 
medieal personnel since double team transfusion is highly desirable in 
the interests of these donors. For example it is clear in retrospect at 
least, that Case 1 should have been transferred and transfused long before 
she was. The fact that transfer “within Hie hour” of the second patient 
appeared to surprise the personnel at the institution, emphasizes that 
the subject is a blind spot to too many persons otherwise well trained in 
maternity care. Had the first patient been transferred early and a 
proper investigation undertaken it is unlikely that we would have had a 
Case 2, while in the light of the outcome of the second case it is possible 
the first might have recovered. Until the significance of this is grasped 
by all connected vdth maternity cave, unnecessary deaths will take place 
periodically. 

Following the transfer of Case 2 a brief survey of the Florence Critten- 
ton Home was undertaken by one of us (A. T. H.) in an attempt to un- 
cover any factors which may have had an epidemiologic bearing on the 
septic outbreak. At no time were there any demonstrable contacts be- 
tween either patient except in the prenatal wards where both spent some 
time prior to delivery. During this period neither showed sjTnptoms of 
any soi’t. During the four days after delivery, the first patient occupied 
a bed in the eight bed postpartum ward. On the third day she had an 
elevation of temperature up to 103.6°. She then remained isolated for 
five days in a single room/ At the end of this period she was sent to a 
large general hospital Avhere she died twenty-four hours later, or ten 
days after delivery, of septicemia and probablj’’ generalized peritonitis. 
No autopsy was done but a pure culture of alpha prime hemolytic strep- 
tococcus (so reported by the bacteriologist) was isolated from the blood 
stream prior to death. Unfortunately this strain was not obtainable at 
the time this investigation was undertaken. 

Both patients were delivered by the same personnel, including the visit- 
ing obstetrician, house ofQcer, supervisor, and nurses. Only the opera- 
tors were masked during the delivery. A feature of interest was the 
fact that both patients occupied the same bed in the iiostpartum ward, 
although they were delivered eleven days apart. During the last seven 
daj's of this period the bed was empty and was aired on the sun porch 
together with the mattress and blankets. All bedding, ivitli the excep- 
tion of the latter articles, was sterilized. It is doubtful if hemolytic 
streptococci could have remained viable under those conditions either on 
the bed or in the bedding. Granting that there might have been some 
etiologic relationship between the first and second case, the former has 
yet to be explained. 



KELLOGG AND HERTIG : PUERPERAL INFECTIONS 


217 


Tlie second patient, after experiencing a chill with elevation of tem- 
perature on the second day, was sent to the Boston Lying-In Hospital 
where she ran a septic course for many weelis but finally recovered. 
During her stay, hemolytic streptococci of a type similar morphologically 
to those isolated from the first patient Avere isolated from her lochia and 
blood stream. 

Because of the lack of demonstrable etiologie factor in either ease, 
throat cultures were taken from all persons who had been in contact 
Avith either patient. These included the visiting obstetrician, house offi- 
cer, the superAusor, and seven duty nurses. All eultures Avere negative 
for hemolytic streptococci except those from tAvo nurses Avhich Avere 
strongly positiA’'e. Each j’^ielded a cultui’ally diilerent strain of hemo- 
Ijdic streptococcus. That from the night nurse possessed a relatively 
large clear colony Avith a faint but distinct zone of hemolysis (as did the 
tAA^o strains from the patients), Avhile the other strain Avas of the usual 
beta type AAdth small, clear colonies, and a Avide, prominent zone of 
hemolysis. Both strains in broth were similar morphologically, possess- 
ing chains averaging eight to tAvelve organisms in length. It is interest- 
ing to note that from both patients culturally similar strains of hemolytic 
streptococci Avere obtained Avhieh corresponded to the type isolated from 
the throat of the night nurse. Incidentally the latter AA^as suffering from 
symptoms of a mild upper respiratory infection during the septic out- 
break. Babbits Avere immunized by injection of these strains in an 
attempt to determine by cross agglutination Avhat, if any, relationship 
there existed betAveen the throat organisms and the one isolated from 
the second patient. The latter strain continually killed rabbits so that 
no immune serum Avas obtained for typing. 

Kegardless of the fact that a positive etiologie relationship between 
one or the other of the throat strains and the second ease of puerperal 
sepsis was not proved, such a relationship has been definitely established 
in one case coming Avithin the experience of one of us (A. T. H.). The 
patient, a para ii, delivered in a private hospital by an easy Scanzoni 
maneuver ran a perfectly normal postpartum course for the first seventy- 
two hours. At this time she had a chill followed by elevation of tempera- 
ture and evidence of a spreading peritonitis. A pure culture of hemo- 
lytic streptococcus Avas isolated from the lochia on the fourth day, and 
from the peritoneal cavity, at autopsy, on the seventh postpartum day. 
Cultui’es were made from the throats of all persons coming in contact 
with this patient, in addition to one from the throat of the patient her- 
self. The only positive culture obtained Avas from the throat of the 
patient’s oAvn priAmte nurse. Subsequent typing of Dr. J. H. Mueller 
of the Department of Bacteriology at the Harvard Medical School showed 
the patient’s strain to be apparently identical with that isolated from 
the throat of the nurse. 

On transfer of patient 2 the folloAving standing orders for personnel 



218 


AJIERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


were immediately posted, put into effect and tlie superintendent made 
responsible for their maintenance. 

RULES FOR NURSES AT THE FLORENCE CRITTENTON HOSPITAL 

1. Graduate and pupil nurses shall be masked and capped at all times when in con- 
tact nith patients as long as the patient is on the hospital floor. 

2. Failure of a nurse to report a cold or sore throat to the head nurse shall be 
followed by summary dismissal without credit if discovered. 

RULE TO HEjVD NURSE REG/VRDING SORE THROATS AND COLDS 

Absolute masking must be insisted upon, and breakers of this rule punished. 

A loose mask around the neck is no protection. 

On receiving a report from a nurse that she has a sore throat or cold, the nurse 
shall be isolated in her omi room and four hour temperatures taken, by the head 
nurse or acting head nurse, iierself masked. The head nurse or acting head nurse 
shall then scrub as for an operation, after each contact. Tlie person servicing the 
nurse shall not be a pregnant inmate and shall not service pregnant or delivered 
inmates, unless she is a graduate nurse in which case she must “Scrub up” ten clock 
minutes after each contact. This event should be reported to the superintendent or 
the acting superintendent who will make provision for cultures to be taken. The 
nurse shall not be allowed out of her room until permission is granted in each instance 
by the chief of staff after consultation with the sui>erintendcnt and report of cultures 
has been obtained. 

It is expected that the head nurse will apply this rule to herself as well. The in- 
fected nurse shall be allowed back at work in the hospital again only with the specific 
permission of the chief of staff. 

No perineal ice bags shall be used under any circumstances in the Florence Critten- 
ton Hospital. 

RULE FOR RESIDENT AT THE FLORENCE CRITTENTON HOSPITAL 

He shall report all temperatures of 100° or over to the staff man, who is supposed 
to see such patients ndthin six hours. If the staff man does not respond within this 
time he shall report the temperature to the chief of staff. 

He shall be masked and capped during aU contact with patients before, during 
and after labor. 

It seems i-easonable to draw the follotving conclusions from the above : 

1. That nasophar 3 mgeal carriers of hemolj'tic streptococci (and perhaps other 
organisms) are a most dangerous source of frequentlj’ fatal sepsis to women in child- 
birth from the moment labor begins (and possiblj’ before) to the end of the puer- 
periuni (at present an unassignable date but at least fourteen daj's after delivery). 

2. That “silent carriers” are potentially as dangerous as persons acutely sick 
with temperatures, save for less likelihood of coughing or sneezmg, although usually' 
a history' of some acute exacerbation in the not distant past may be obtained from 
the carrier. 

3. That perineal contacts are presumably the most frequent method of transmis- 
sion; either by' coughing, sneezing, or talking with the patient during perineal pre- 
cautions or by incomplete manual asepsis after self infection of the hands by the car- 
rier, as by the use of a handkerchief; but that for the present other less direct meth- 
ods must be assumed, and guarded against. 

4. Hence that every carrier is a source of danger and must be ebminated or be 
masked adequately at all stages of labor and the puerperium and be absolutely tiained 
and trustworthy about digital asepsis. 



219 


KEliliOGQ AND HERTIG : PUERPERAL INFECTIONS 

5. That since pupil nurses are untrained and unhabited to conscientious^ digital 
asepsis, it is a v,'isc precaution to culture each one on entrance to a maternity hos- 
pital and to eliminate each one temporarily until the throat is negative for hemolytic 

streptococci. _ . ■ i 

6. That other personnel, i. e., doctors and graduate nurses trained in asepsis, lol- 

loiving rules akin to those given above, ivill in all probability not prove a hazard to 
patients. 

7. That the question of ward attendants, especially those serving food must be 
carefully considered. 

8. That a single case of puerperal sepsis in an institution calls for immediate ligid 

investigation and drastic measures based on this to limit spread. 

"We wish to express our gratitude to the unnamed collaborator.s in this paper 
without whose cooperation and sanction it could not have been written or puhlishea. 

19 Bay State Koad. 

ABSTRA.GT OF DISCUSSION 

DE. EDWAED SPEIDEL, LouistULhE, Ky. — ^IVith all the precautions mentioned 
in protecting our patients from this kind of infection we lose sight of the greatest 
menace of all, the visiting public that enters the hospital. Unless we have an oppor- 
tunity to limit this nuisance of excessive visiting in hospitals, especially in maternity 
hospitals, I fear that all of the precautions mentioned in tlie paper will be nullified. 

There is another item that should be considered. Fever may occur in patients 
where the delivery was conducted without any e.xamination, or in such manner that 
infection could not have been introduced. In many of those cases the patient probably 
had a gonorrhea in the cervix and in the course of the puerperium these organisms 
became very virulent and caused elevation of temperature. 

DE. BETHEL SOLOMONS, DtraUN, Irelakd. — In our institution we arc not wear- 
ing masks and are not having trouble. I have taken some series of throat swabs 
when there were no infections and got exactly the same results as when there were 
infections. You may say, but why not take that little extra precaution and wear 
masks? I have been in hospitals in various places where masks were worn, the masks 
being sucked in and covered -with saliva. Lachlan Grant, medical officer of liealth 
in Argyle, Scotland, has written a very fine paper, condemning masks on account of 
the moisture that collects. 

DE. KELLOGG (closing). — Kegarding masks, there is no question that the present 
mask in use is inadequate and we are working, as some others are, to got a more satis- 
factory mask. Sepsis is a relative thing anyway. If a mask is worn in a laparotomy, 
and I take it most people do this, it seems rather queer jiot to mask over an open 
wound in a perineum. 

In discussion of almost any obstetric problem, there always arises in my mind a 
suspicion that local conditions in different places vary. Now the hemolytic strepto- 
coccus of Dublin and that of Boston may be qualitatively or quantitatively different. 
When, for example, we reported 25 per cent mortality in eclampsia, and others say 
that they would be glad to come to Boston and teach us how to lower our mortality 
we begin to suspect that the type of eclampsia may differ in different regions. ^Ye 
do liave in New England an extremely -rirulent and a very pernicious hemolytic strep- 
tococcus each season, which appears to cause a good many clean cases each year to 
end fatally. ■' 



ijNJUEY TO^ U BETEBS INCLUDING ACCIDENTAL LIGATION 
DUBING PELVIC OPEBATIONS^^ 

Quitman U. NE^^^2LL, M.D., F.A.C.S., St. Louis, Mo. 

(From the Dcjmrtincnt of Obstetrics and Gynecology, Washington University 
Medical School and Barnes Sospital) 

T WAS prompted to make a stud}^ of this subject, because recently I per- 
formed a complete abdominal liystcreclomj’’ for carcinoma of the fundus 
uteri, and thirty-six hours after operation, the patient died from an 
acute dilatation of the heart. The autopsy showed, in addition to the 
heart condition, that I had ligated the left ureter about 5 cm. from the 
bladder. The right ureter was in normal condition, although the patient 
did not pass anj’’ urine folloudug the operation. I desire to report the 
histoiy of the patient in question, also other eases in which the ureters 
were either ligated or injured during pelvie operations in the Gjmeeologi- 
eal Service of Barnes Hospital, from Jan. 1, 1915, to July 1, 1932. 

Prom Jan. 1, 1915, to July 1, 1932, in the Gjmecologieal Service of 
Barnes Hospital, 1784 ly'stereetomies were performed for various reasons. 
Of this number 519 were complete abdominal hysterectomies, 63 were 
complete vaginal hysterectomies and 1202 were abdominal supravaginal 
hysterectomies. During the course of these operations, one or both ure- 
ter were knovdugly injured bj’ clamping, cutting, tjdng or interfering 
with the circulation in some manner in eight eases. This is an unusually 
small number of injuries as compared to the number of hysterectomies 
performed. I am sure one ureter is occasionally ligated and the con- 
dition is unrecognized and the kidney on the corresponding side dies 
before the ligature around the ureter is absorbed. 

During the postoperative course, there are no definite symptoms to 
show that onl 3 '- one kidney is functionating. Of course, if both ureters 
are ligated, the patient has an anuria and bj^ cj'stoscopic examination the 
diagnosis is easily established. 

Most gjmeeologists regard operative injurv of the ureter as exceptional 
and nearly all are in accord in believing unilateral injury fairlj'^ common 
and bilateral injurj’- exceedinglj'^ rare. Thej^ describe ureteral injuiy as 
the most common accident in pehde work. 


CASE REPORTS 

Case 1. — Mrs. A. P. B., aged sixty-seven years. Hospital No. 22954. Admitted 
Dec. 26, 1929, for vaginal bleeding. A very large obese patient vreigbing 19S pounds, 
with a chronic myocarditis and hypertension of 176 over 98. She presented a carci- 
noma of fundus uteri. A medical consultant classified her a fair operative risk. An 
abdominal operation was considered the treatment of choice. This was preceded by 


‘Read at the Forty-fifth Annual Meeting- of the American Associa^ 
stetricians, Gynecologists and Abdominal Surgeons, French Lick Spring , ■. 

tember 12, 13, and 14, 1932. 


220 



NEWEIjIi: injury to ureters 


221 


diagnostic dilatation and curettage, and the laboratory reported adenocarcinoma of 
the fundus uteri. On Jan. 4, 1930, at time of laparotomy, it was noted that patient 
had two uteri and two cervices. This w-as not diagnosed before operation as the 
cervix on the right side had not been seen during speculum examination. However, 
a lot of sear tissue was found extending the entire length of the anterior vaginal wall. 
Probably the result of extensive vaginal lacerations during childbirth. A small mass 
was palpable in the right side of pelvis in apposition to a normal uterus which was 
felt in a forward position. The mass was thought to be a prolapsed adnexa or some 
parametrial infiltration. There was a band of peritoneum extending forward from 
the sigmoid to the central part of the top of the bladder. It was ligated and severed. 
The two uteri were fully developed, the one on the left side was slightly larger than 
the one on the right. They were attached to each other at about the internal os and 
continued into the vagina. Attached to each fundus was one tube and one ovary. 
Complete hysterectomy with removal of both tubes and both ovaries were performed 
in the usual manner. All the clamped pedicles were ligated, the tuboovarian and 
upper broad ligament pedicles were ligated before the uteri were removed. There 
was insufficient bladder peritoneum to cover the ligated pedicles so some raw surfaces 
were left exposed. At no time during the operation were the ureters visible. The 
appendix was not removed. Abdomen closed in routine manner and retention catheter 
placed in position. The operation was fairly difficult due to exeessive fat in the 
pelvis. 

Postoperative Course . — Patient returned to ward in fair condition and immediately 
was given 1500 o.c. normal saline solution subcutaneously and 500 c.c. 10 per cent 
glucose solution intravenously. Six hours after operation patient was fully conscious 
and had no unusual complaint. The blood pressure was 152 over 98. No urine had 
passed per catheter. She had a fairly comfortable night and next morning seemed 
to be in good condition, no unusual abdominal pain, no distention, no pain over 
either kidney region. No urine had been obtained per catheter since operation 
twenty hours previous. It was then realized that anuria had developed. Additional 
saline and glucose were given and fluids were forced by mouth along with treatment 
to stimulate diuresis. Thirtj' hours after operation patient began showing signs of 
uremia with evidence of myocardial failure. No urine had passed up to this time. 
Thirty-six hours after operation patient expired. An autopsy was performed and 
the cause of death was given as acute dilatation of heart, chronic myocarditis, chronic 
nephritis and arteriosclerosis. During the course of the autopsy it was found that 
the left ureter was ligated about 5 cm. from the bladder. The right ureter was in 
good condition. There was no marked difEerence in either of the kidneys. They 
did not show evidence of hydronephrosis, etc., as you would expect in case of ob- 
structed ureters. No doubt, the anuria was the result of constitutional causes and 
not the result of ligation of the left ureter. 

Case 2. — Mrs. A. H., aged thirty-five years. Hospital No. 818. On May 11, 1916, 
she was operated upon for myoma of the uterus. A supravaginal hysterectomy with 
double salpingooophorectomy were performed. The postoperative course was stormy 
and on the fourth postoperative day patient showed signs of uremia. No urine had 
been obtained since operation; cystoscopie examination revealed both ureters blocked 
a short distance from the bladder. It was then decided to open the abdomen and 
attempt to deligate the ligated ureters. A description of the operation is as follows: 
Abdomen opened through old incision. Much fibrin and clear serous fluid were pres- 
ent. The right kidney was enlarged ndth the ureter distended to about the size of 
small finger. About 2 cm. below the pelvic brim a ligature was found around it, 
a second ligature was around the ureter at about the position of the internal os of 
the uterus. The Ugatures were cut and the ureter freed. Left ureter apparently was 
not definitely ligated but edematous and enlarged. The stumps of the cut adnexa 
and ligaments of the uterus had been drawn over the ureter during previous operation. 



222 


AJSIERICAN- JOURNAL OP OBSTETRICS AND GYNECOLOGY 


These sutures were cut and the ureters freed. Abdomen closed hurriedly with drain- 
age. Patient returned to ward in poor condition. She died from general peritonitis 
thirteen days after the operation. There is no history of any passage of urine fol- 
lowing operation. 

Case 3. — iNIrs. B. P., aged sixty-si.\ years. Hospital No. 2031. On Sept. 22, 1919, 
was operated upon for cancer of cervix uteri. A complete vaginal hysterectomy and 
double salpingooophorectomy were performed. The postoperative course was stormy 
and thirty da 3 ’s after operation urine dribbled from the vagina. Cj'stoscopic examina-, 
tion revealed a left nreterovaginal fistula. She was discharged from hospital after 
thirty daj's nitli ureterovaginal fistula present. She reentered the hospital later and 
reported the dribbling of urine from tlic vagina ceased after eight months. Cj'sto- 
scopic examination at this time revealed no function of loft ureter with a dead kidney. 
Eight kidney in good condition. Patient also had diabetes mellitiis. 

Case 4. — Mrs. B. S., aged forty-three j'oars. Hospital No. 2206. On April 16, 
1920, was operated upon for rotrodisplacemont of uterus, chronic cervicitis and ej’s- 
toma of right ovarj-. A complete abdominal hj’stcrcctomj’ with double salpingo- 
oophorcctomj' wore performed. The postopor.'itivc course was stormy. Twelve dnys 
after operation a rectovaginal fistula and a ureterovaginal fistula were noted. She 
was discharged from hospital twent 3 '-cight d.a 3 's after operation with ureterovaginal 
fistula present. Tlio rectovaginal fistula closed spontancousl 3 '. Patient reentered 
the hosxiital two months later complaining of dribbling urine from vagina. C 3 ’sto- 
scopic examination revealed no function from right ureter into bladder. The left 
catheter passed easily and function Avas normal. The right kidney Avas large and 
filled AAdth pus. A right nephrectom 3 - AA-as performed. The postoperative course Avas 
uneventful, and patient Avas discharged from hospital tAventy days after operation. 

Case 5. — Mrs. M. W., aged fort 3 ’-four 3 ’cars. Hospital No. 2260. On Juno 8 , 

1920, she AA-as operated upon for ni3-oma of uterus (large). A complete abdominal 
h3-stcrectom5- and double salpiugooophorectom3' AA-cre performed. The postoperative 
course AA-as stornu’. Four days after operation a ureterovaginal fistula developed 
AA-hich persisted throughout hospitalization. She Avas discharged from hospital forty 
da3-s after operation Avith ureterovaginal fistula present. Cystoscopic examination 
made before discharge from hospital reA-ealcd bladder normal: right catheter passed 
easil3’ to kidne3'. Loft catheter met obstruction 3 cm. from bladder. Patient ad- 
vised to go home and come back later for treatment for ureterovaginal fistula. She 
never returned to hospital and nothing further Avas heard from her. 

Case 6 . — Mrs. W, M., aged thirt 3 --ninc 3 -ears. Hospital Ho. 10903. On JUI 3 ’ 14, 

1921, she Avas operated upon for early carcinom.a of cerA-ix uteri. A complete lu’s- 
terectom3- Avith double salpingooophorectom3' AA-ere performed. During the operation 
both ureters were isolated and apparent^ not injured. The postoperative course 
was moderatel3' storm3'. Eight days after operation a ureterovaginal fistula devel- 
oped. She was discharged from hospital thirt3'-four da3-s after operation Avith ure- 
terovaginal fistula present. Patient reentered the hospital four months later, at 
Avhich time C3-stoscopic examination reA-ealed normal bladder. Left catheter passed 
easil3' to kidney. Eight catheter met obstruction 2i/(> cm. from bladder. She Avas 
discharged from hospital to return tAvo months later for operation on ureterovaginal 
fistula. She reentered the hospital at the appointed time and the operation aaus 
carried through, making a right inguinal incision. The ureter was isolated and 
found greatl3- distended and led from the kidney to the vaginal vault. It Avas freed 
and transplanted into the bladder AA-ithout tension. Three da3-s after operation urine 
flOAved from the abdominal incision and it was plainl3’' seen that an abdominoureteial 
fistula had formed. After thirty days urine ceased to flow from the Avound and it 
healed nicel3'. Patient was discharged from hospital Avithout doing a cystoscopic 
examination. January 1, 1931, nine and one-half 3-ears after first operation c3'sto- 



NEWELL: INJURY TO URETERS 


223 


scopic examination and x-ray plate showed a dead right kidney. ITunction of left 
kidney normal. 

Case 7. — ^Mrs. A. C., aged twenty-nine years. Hospital No. .16862. On Sept. 4, 
1928, she was operated upon for' myoma of uterus. A supravaginal hysterectomy 
with double salpingooopiioreetomj' were performed. During the course of the opera- 
tion the right ureter was severed near the 'bladder. It was immediately transplanted 
into the bladder without tension. The postoperative course was stormy and the 
patient complained of great pain in right kidney region. No fistula developed. A 
few days after operation it was discovered patient had a right pyonephrosis and the 
transplanted ureter was not functioning. Thirty days after operation the right 
kidney was removed. She had an uneventful postoperative course and was discharged 
from the hospital nineteen days later in excellent condition. 

Case 8. — Mrs. D. C., aged forty-nine years. Hospital No, 30848. On August 13, 
1931, she was operated upon for chronic subinvolution of uterus and chronic salpin- 
gitis. A complete abdominal hysterectomy with double salpingooophorectomy were 
performed. The postoperative course was markedly febrile. Patient discharged 
from hospital Aug. 31, 1931, eighteen da 3 's after operation with some temperature 
present. On the seventeenth postoperative daj* dribbling of urine was noticed com- 
ing from the vagina. She was discharged with this condition present. Two months 
later patient began having severe pain in the lower abdomen, chills, and temperature. 
She urinated often and passed small quantities of urine. On Oct. 22, 1931, she re- 
turned to Barnes Hospital complaining of urine passing from vagina. Patient ad- 
mitted to the Genitourinary Service and a diagnosis of ureterovaginal fistula was made, 
Cystoscopic examination revealed a good left kidney and ureter. The right catheter 
met an obstruction about 2 cm. from the bladder. On Nov. 11, 1931, a right nephrec- 
tomy was performed. The kidney was enlarged twice its normal size and the patho- 
logic report show'ed an acute hj’droncphrosis with chronic pyogenic nephritis. Patient 
had an uneventful postoperative course and was discharged from the hospital Nov, 27, 
1931, in excellent condition. 

Much of the literature dealing with ureteral injurj’- and ligation is in 
the form of ease reports. However, in tlie past fetv years the subject is 
recei-ving more attention and a few investigators have attempted to cor- 
relate the cases and large series have been reported. P. Brooke Bland 
has collected 441 cases, 361 were -nnilateral and 81 bilateral injuries or 
ligations. Of these Leon Herman reported 24 cases, all bilateral. Bar- 
ney has reported 62 cases including 32 presented by Sampson in 1902, 
and Oeeonomos has collected a series of 159 cases. The additional 196 
cases were from several investigators in vaxnous parts of the country. 
Forty-two surgeons reported 125 cases ranging from one to eight. 
H. Kayser reported the cases in the clinic of Professor Franz, Charite 
Hospital, Berlin, for five-year period. He listed 29 instances of injury 
or ligation of the ureters and quotes 'Wertheim as having had 49 injuries 
among 500 hysterectomies for uterine carcinoma. T. S. Burr refers to 
630 hysterectomies for cancer of the uterus in which a single ureter was 
injured 13 times and both ureters once. 

From a stndj^ of the cases reported, it is evident the greatest percent- 
age of ni’eteral injuries followed radical hysterectomies for uterine carci- 
noma and the most common sequelae were ureterovaginal fistulae. 

Most of the textbooks in gynecology outline the treatment for ureteral 



224 


.UIERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


fistulac following injury in wliieli the ureter may he cut or crushed Muth 
a clamp, or the blood supply interfered with to such an extent that 
necrosis and sloughing follows. Very little is said about the treatment 
when one or both ureters arc ligated. 

From an analytical study of the eight cases reported in this presenta- 
tion, together with a careful consideration of the several hundred cases 
reported in the literature by numerous excellent investigators, I desire 
to offer an opinion as to Avhat method of treatment seems most suitable 
for handling this most perplexing problem. In presenting this, I should 
like to sound the warning note of prophylaxis. I am quite sure many 
cases of ureteral injury can be avoided if modern technic is foIIoAved 
when performing an extensive pelvic operation. I am sure every gjme- 
cologist is conscious of the fact the ureters may be injured during the 
course of almost any pelvic operation. The radical abdominal hysterec- 
tomy opex’ation for uterine carcinoma tops the list of ureteral injuries, 
vaginal hysterectomy next, then complete abdominal hysterectomy for 
myoma, etc. Therefore, when peiTorming any of these operations, or 
any other extensive pelvic operation, I would suggest as a prophylactic 
measure, that the ureters be isolated according to the familiar technic. 
As an additional safeguard catheters may be inserted into the ureters 
before starting the operation, as suggested by Kelly many years ago. 

At ihe Time of Operation . — If it is discovered that one or both ureters 
haA’'e been ligated, the proper treatment is to deligate as soon as the con- 
dition is recognized. Ordinarily, the ligature around the ureter is not 
sufficient to cause permanent injury. If one or both ureters have been 
severed, a ureteroureteral anastomosis should be performed by one of 
the various accepted methods. Transplanting the ureter into the blad- 
der is only fairly satisfactory, as the contraction of the wall of the blad- 
der constricts the ureter, eventually causing a pyonephrosis and death 
of the kidney/ Some few successful cases of ureteral transplant into 
bladder have been reported. Of course, if the patient is in bad shape 
and only one ureter is damaged, a ligation may be done, which will cause 
death of the kidney. This is a sacrificial operation and only considered 
as a last resort. The ureteroui’etei*al anastomosis operation is the one 
of choice. 

Peterson in an analysis of 72 eases of ureteroureteral anastomosis has 
shown it is usually successful, claiming that the different methods are 
equally effective in the hands of different operators. He found in 29 
eases of the end to end operation, leakage occurred in 9. In 25 end 
in end operations leakage occurred in 5, and in 15 end in side operations 
leakage occurred in only 2. As to final results one must consider in all 
these operations that in a small percentage of the cases there will be 
contraction of the scar at the site of the ureteral repair with complete 
occlusion of the ureter and death of the kidney on that side, but as a 
whole this is negligible. 



NEWEDb: INJURY TO URETERS 


225 


A. H. Curtis lias described a simple and practical method of end to 
end ureteral anastomosis. A ureteral catheter is passed into the cut 
ureter and the lower end brought out through the bladder and urethra, 
the two ends of the ureter are sutured together, taking care not to pene- 
trate the lumen of the ureter ivith the sutures. A second ureteral 
catheter is placed into the ureter above the point of the anastomosis 
through a small slit and passed up to the pelvis of the kidney so as to 
divert the passage of the urine awaj’- from the regular course. This 
catheter is brought out througli a stab wound in the flank. After ten 
days both catheters are removed. 'Warner S. Bump and )Stanley IM. 
Crowe of the Gynecological Department of Northwestern University 
Medical School worked out the technic on dogs and the operation was 
successfully performed six times. In not a single case did a urinarj’- 
tract infection take place and necropsy of .the animals showed perfect 
function of ureter and kidney. Curtis has performed the operation once 
upon a woman with complete success. He has made no other attempts. 

Such a technic is both practical and simple. Heretofore, many failures 
of end to end anastomosis have been due largely to infection following the 
leakage of urine around the end to end contact, causing peritonitis or ad- 
hesions about the ureter, later resulting in contraction of the ureter at the 
site of the anastomosis, hydroureter and death of the kidney. With the 
use of the ureteral catheter as a splint, the operation need not necessarily 
be water tight. Coaptation of the two ends over the catheter with enough 
fine sutures to make them fast is all that is necessary, as the catheter which 
has been passed up to the pelvis of the kidney and brought out through 
the flank reroutes the urine and thus allows epithelization of the ends of 
the severed ureter to take place. 

If it is discovered that the ureter has been crushed by a clamp, the in- 
jury should be carefully examined and if it is determined to be severe, 
end to end anastomosis should be done in order to prevent a uretero- 
vaginal or ureteroabdomiual fistula. If the injury is not severe, circula- 
tion may be restored and healing take place without fistulas forming. 
Purniss reports two eases in which clamps were on the ureters from seven 
to eight minutes and in both instances fistulas developed, one in eight 
days, the other after twenty days. Crossen in a personal communication 
informed me he had placed a clamp on a ureter for several minutes and 
a ureteral fistula followed. Kayser mentions seven eases in which only 
the sheath of the ureter was injured and of these, two developed fistulas. 
Harrington crushed the ureter in dogs with a forcep from one to thirty 
minutes and noted no fistulas forming, but at the point of crushing, scar 
tissue formed with constriction and dilatation of the ureter thus leading 
to hydronephrosis and degeneration of the kidney. 

Several Days After Operation . — ^If both ureters have been ligated and 
this IS not discovered until two to four days after operation, the condition 



226 


AiMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


is a serious one. Tlie patient ordinarily has a complete anuria with 
uremia and something very urgent must be done. Two things are to be 
considered: (1) Deligation of the ligated ureters. (2) Nephrostomy. 
Not enough cases have been handled by eitlier method for one to draw any 
definite conclusion. Of course, deligation is the operation of choice, if 
the patient’s condition is such she can endure a serious operation. It 
must be remembered that uremia is present and ordinarily the patient is 
a poor operative I'isk, and searching for the ligated ureters is not easy, 
also after locating them, can the patient stand a ureteroureteral anasto- 
mosis or whatever sort of operation one deems fit and proper? On the 
other hand, is nephrostomy the choice? Certainly, it seems to be the best 
operation when the patient’s condition is grave, as it can be quickly car- 
ried out, and when the patient’s general condition improves, if necessary, 
then deligation may be attempted. As regards double nephrostomy, 
Caulk has made the following statement: “In double ligation, your only 
chance is to do a double nephrostomy as quickly as you can. The ideal 
method would be immediate deligatiou, but this is attended with consider- 
able difficultj', as searching for a tie on a ureter deep in the pelvic cavity 
several days after an extensive resection is difficult. Even in animals it is 
difficult to untie without cutting the ureter. In several instances in which 
I have known of its being done clinically, the ureter had been incised with 
a resulting fistula or a ureterovesical anastomosis performed at the time.” 
Caulk and Fischer’s experimental work on ureteral ligation on the dog 
is very interesting and deserves considerable thought. They have sho-wn 
that No. 2, iilain catgut when tied around the ureter was never absorbed 
before the end of three weeks, and that twenty-day and forty-day chromic 
catgut, which is the most commonly used in j^elvic work is not absorbed 
for a much longer time, so it is useless to wait for the absorption of the 
catgut. 

I cannot fully agree with Caulk and Fischer as to the length of time 
catgut lasts in the human pelvis. In the dog the absorption of catgut may 
be very slow and extend over a period of many days, but in the human 
being I am quite sure catgut is more readily absorbed, and the time of 
absorption is in proportion to the kind of catgut used. My opinion is 
based on the fact I have had occasion to open a few abdomens seven to 
twelve daj^s following pelvic operations and have in some instances found 
the No. 2, twenty-day chromic catgut pi'actically absorbed. 

Caulk’s conclusions were no doubt drawn from this piece of experi- 
mental work on the dogs and the successful management of a ease of 
double ureteral ligation in a patient who came under his care. The pa- 
tient on whom both ureters had been ligated during the coui'se of a com- 
plete abdominal hysterectomy for fibroids, had not passed urine for eight 
days. It was recognized early that both ureters had been tied but the 
surgeon awaited developments, thinldng that possibly the catgut would 



NEWELL: INJURY TO URETERS 


227 


loosen and the ureters Avonld open spontaneously. At the end of the 
eighth day the patient became nremic. He performed a double nephros- 
tomy upon her and during the next twelve hours 3000 c.c. of urine were 
secreted. Drainage through the nephrostomy tubes was free until the 
fifty-eighth day when the patient voided. Ten days later the urine was 
passed entirely by the bladder and the wound had healed. In a personal 
communication, Dr. Caulk infoi’med me the patient is now living and 
enjoying good health. 

This brings up the question of how long can a patient live with com- 
plete anuria. Caulk’s patient had anuria, for eight days. Myers reports 
19 cases of complete anuria lasting from twenty to twenty-nine days. 
Parlow reports a ease lasting thirty-five days, PaiT forty-two days and 
Daily fifty days. However, these cases did not follow double ureteral 
ligation. 

The arguments for bilateral nephrostomy as advocated by Caulk are 
most convincing, but when one searches the literature carefully he finds 
that Caulk’s eases of double nephrostomy are the only successful cases re- 
ported. E. S. Judd reports a ease of double nephrostomy who had an 
anuria for three days and seven days after the operation passed urine 
from the bladder. This case does not seem to be one of double ui'eteral 
ligation but rather one of urinary suppression. 

Herman cites 24 eases of bilateral occlusion, 15 of which were due to encircling 
ligatures. The other 9 were from various causes. Of these 24 patients, 1 died without 
operation and the remaining 23 were operated upon. Seven died immediately fol- 
lowing operation, a primary mortality of 30.4 per cent. The primary mortality among 
the 10 nephrostomy cases was 50 per cent. Among the 8 cases of deligation it was 
25 per cent. All of the patients, 6 in number, who recovered from the operation of 
dehgation were cured permanently. 

In dealing with bilateral ureteral ligations the following conclusions are drawn : 

1. The method of treatment, selected for the relief of bilateral ureteral obstruc- 
tion will depend upon the cause of the obstruction, upon the individual choice of the 
operator, and upon the time that has elapsed since the receipt of the injury. Also, 
upon certain factors that were present at the time of the primary pelvic operation. 

2. Delay in operative treatment is dangerous and will eventually result in death. 

3. That deligation is the treatment of choice provided the patient’s general condi- 
tion can stand the strain of serious operation, and if not nephrostomy with drainage. 

Ureteral Msholas . — ^Ureteral fistulas which are the most common se- 
quelae of ureteral injury, usually occur from three to twelve days after 
operation and may be either vaginal or abdominal, the former more com- 
mon than the latter. Ureteral fistulas occur (a) when the ureter is sev- 
ered, either partially or completely, or (b) the blood supply so injured by 
clamping, etc., that necrosis occurs, or (c) as a result of stripping the 
ureter of the blood supply, necrosis follows. A cystoscopic examination 
with ureteral catheterization should be performed in order to locate which • 
ureter is not functionating into the bladder, and also to determine the 



228 


AMERICAN' JOURNAL OP OBSTETRICS AND CiTNECOLOGY 


condition of the other kidney. It is probably best to wait from one to sis 
months after the primary operation before attempting operation from the 
cure of the ureteral fistula as sometimes from the sear tissue contraction, 
the fistula is cured spontaneously. Usually in such cases a hydro- 
nephrosis develops Avith infection and death of the kidney, but if opera- 
tion is attempted too early after the formation of the fistula, the patient 
is not in a suitable condition to stand the operation, Avhereas, after one to 
six months much better results would be obtained. 

In selecting the t 3 ’pe of operation for the cure of this condition, one 
must consider ureteroureteral anastomosis, ureteral A’esical anastomosis 
and ureteiml transplant into skin, bowels, etc., also ligation of ureter and 
nephrectomy. The aim of any operation should be to preseiwe the kidney 
and not destroy it unless nothing else can be done. Sevei*al vaginal opera- 
tions have been recommended for ureterovaginal fistula correction, col- 
pocleisis, ureterovesical anastomosis, etc., hut none of them seem to be 
satisfactoiy. It seems to me that the best plan to follow in dealing with 
ureteiwaginal and ureteroabdominal fistulas is to put the plain facts of 
the condition to the patient, state the chances of a failure if anastomosis 
is attempted and that it might be neeessaiy to undergo a second operation 
for removal of kidnej-. Also, discuss the removal of the kidney on the 
affected side, after the other kidnej’’ has been pronounced normal, and if 
she desires, a nephrectomy maj’- he performed outright and thus avoid 
the possibility of two serious operations. 

CONCLUSIONS 

1. From the large number of cases of ureteral injury reported, it is 
evident that the accident is a surgical complication far more common than 
one Avould suspect. 

2. No doubt some unilateral ligations occur during the course of pelvic 
operation and are unrecognized, the ultimate result being death of the 
kidnej’’ on the corresponding side. 

3. The accident is liable to follorv almost any pehde operation, but 
usually after radical abdominal and vaginal fij’^sterectomies. 

4. In most eases the injury is unilateral. In a certain number of cases 
both ureters are involved. 

5. The most common sequelae of ureteral injurj^ are vaginal and ab- 
dominal fistulas. 

6. As a surgical complication, ureteral injury is responsible for a cer- 
tain number of deaths. 

7. Prophylaxis is most important, 

8. Should a ligature or clamp be placed on a ureter and serious damage 
inflicted, immediate repair should be done in the form of ureteroureteral 
or ureterovesical anastomosis. 

9. In case of bilateral occlusion discovered a few daj^s after operation. 



NEWEIili-. INJURY TO URETERS 


229 


removal of the ligatures indicated if patient’s condition can stand t e 
strain of a serious operation; if not neplirostomy ivitli drainage. 

10. Nephrostomy is a life-saving operation and should be done in a 
cases of double ureteral obstruction Avhen the patient ’s condition is grave. 

11. Vaginal correction of ureteroAfaginal fistula is unsatisfactory. Ab- 
dominal operation is the choice either in the form of ureteral anastomosis 
or nephrectomy. 

12. An operation designed to correct a damaged ureter should aim to 
preserve the normal ureteral and kidney function. 


REFERENCES 

(1) Baihj, T. L. W.: Charlotte M. J. 7: 537-540, 1S95. (2) Barney, J. B : Trans. 
Am. Assn. Genito-Urin. Surg. 7: 201-228, 1912. Barney, J. D : iUn. Surg 51: 
362-381, Mareh, 1910. (4) Barney, J. D.: Snrg. Gyuec. Obst. 15; 290-^5, 1912. 

(5) Bland, B. B.: Atlantic M. J. 27; 341-356, March, 1924. (6) Bump, ^ and 

Crowe, S.M.: Surg. Gj-nee. Obst. 49 ; 346-351, 1929. (7) Burr, T. S.: ^ 

Detroit, Mich., 1902. (8) CaulTc, J. JR., and Fischer, B. F.: Surg. Gynec. Obst. 

343-349, 1920. (9) CaulTi, J. R., and Fischer, R. F.: Trans. Am. Assn. Genito-Unn. 

Surg 10- 72-81 1915. (10) Crosscji, S'. S..- Personal Communication. (11) Curtts, 

A. S.: Surg. Gynec. Obst. 48; 320-322, 1929. (12) Farloto, J. W.: Boston M. & S. J. 
120: 330-334, 1889. (13) Furniss, E. D.: Surg. Gynec. Obst. 27: 339-342, 1918. 

(14) Earrington, S. TV.; Arch. Surg. 2; 547-592, 1921. (15) Eerman, Leon: 

J. Urol. 9; 151-179, 1923. (16) Judd, E. S.: Lancet 31; 543-547, 1912. (17) 

Zayser, E.: Med. Press & Circ. 99-106, 1915. (18) Keely, E. A.; J. A. M. A. 24: 

860-864, 1900. (19) Myers, TV. A.: J. A. M. A. 85: 11-13, 1925. (20) Farr, B.: 

London Medical Dictionary 1; 836, 1819. (21) Peterson, R.: Surg. Gynec. Obst. 

31: 132-142, 1920. (22) Sampson, J. A.: Am. Med. 4: 693-700, 1902. (23) 

Oeconomos, Sp. N.; Gaz. d’hop., Paris 94: 197-204, 1921. 

411 Wall Building. 


ABSTRACT OP DISCUSSION 


DR. B. Z. CASHMAN, Pittsburgh, Pa. — In extensive pelvic dissections, and par- 
ticularly in bilateral intraligamentous tumors, if there is doubt as to the location of the 
ureters, they should be exposed and kept in the field of vision at all times. The use of 
radium in the treatment of carcinoma of the cervix, instead of the Wertheim operation, 
should undoubtedly decrease the incidence of ureteral injury, but I am afraid that 
this will be counterbalanced by the present tendency to do total hysterectomy for be- 
nign conditions of the uterus. I looked up our cases in the Magee and St. Francis 
Hospitals in Pittsburgh and will give the figures for comparison. Dr. Newell reports 
1202 supravaginal hysterectomies with 2 ureteral injuries. We had 1419 supravaginal 
hysterectomies with 2 ureteral injuries, practically the same. He reports 63 vaginal 
hysterectomies with 1 ureteral injury, while we had 110 vaginal hysterectomies with 
no ureteral injury. But in, total hysterectomy he reports 5 ureteral to our 1. How- 
ever, on examining the figures, I find that total hysterectomy was done 4 times as often 
in his series as in ours, and therein lies the story. 

The principle of total hysterectomy is correct in that it removes a diseased cervix, 
but this can be accomplished in a much more simple manner, by thoroughly cauterizing 
the cervbc and doing supravaginal hysterectomy. It has been stated that as most of 
the caremomas of the cervix are of the squamous cell type, carcinoma develops from 
the squamous epithelium and therefore it is necessary to remove the entire cervix. We 
maintain that cai-cinoma develops from tlie squamous epithelium only, because of 
the adjacent chronic infection, inflammation and irritation, and that if this is 
thoroughly destroyed with the cautery, it heals over with squamous epithelium and 
there is no more danger of carcinoma arising in that cervical stump than in the 



230 


AISIERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


squamous epithelium of the vagina. There has been no development of carcinoma 
in the cervices of our 1419 supravaginal hy.stcrectomics, all of which were treated 
in tliis manner. On the other hand, in a series of 150 cases of carcinoma of the cervix 
analyzed a few years ago, we found that four had developed in the cervix after supra- 
vaginal hysterectomy, in which the cervix had not been cauterized nor was any 
method used for eradicating the infection in the cervix. 

In the very obese patient, in the deep narrow pelvis, or when the cervix is fi.xed by 
deep tears or by eontraction of parametrial tissue from long standing inflammation, 
total hysterectomy is .a much more difficult procedure, exposure is difficult and it is 
in this type of patient that the ureter may be damaged. If one then decides to do 
supravaginal hj’stcrectomy, a diseased cervix is left behind, thus defeating the very 
purpose of this opcr.'ition. 

In bilateral ureteral injury, while deligation would seem to be the ideal treatment 
in that it permanently corrects the trouble, it is much less certain and therefore is 
not always the practical operation. The condition of the patient and the nature of the 
original operation will help one to decide. If it is felt that the ureters were severed, 
nephrostomy is the procedure of choice. Bilateral nephrostomy is a certain method 
of relieving tlic back pressure on the kidney, the emergency which confronts the pa- 
tient. The mortiility of 50 per cent for nephrostomy as given by Dr. Newell is too 
high, I believe, and is due to delay in operating. In a patient who has anuria the 
next daj- after pelvic oper.ation, the passage of ureteral catheters will quickly deter- 
mine whether it is suppression of urine from nmlfunction of the kidneys, or anuria 
duo to ureteral obstruction. If it is the latter, operation should bo done at once and 
not after three, four, five, or six days. 

DR.. JAMIES R. MILLER, IlARTFOKn, Conn. — I wish to report a case which is 
unusual in some respects. The patient came to me in May, 1926, with a small fibroid 
uterus and a largo cystadcnocarcinoma of the ovary the size of a 32 weeks' pregnancy. 
At operation about two inches of the right ureter were removed accidentally. The 
bladder end of the ureter had been ligated at the time of hysterectomy. The sigmoid 
was fortunately movable and was sutured to the right brim of the pelvis and, not know- 
ing at that time what the Coffey method was, I implanted the ureter into the right 
sigmoid practically with the same technic. This patient has survived six and a quarter 
years, and aside from a single attack of pyelitis on the fourth day, has been entirely 
free from symptoms. Her bowels move three or four times in the morning without 
discomfort .and she never has to resort to a cathartic. This spring I had her come 
into the hospital and was able to visualize both kidneys. 

DR. NEWELL (closing). — I think Dr. Cashman is perfectly right about the pro- 
portion of total hysterectomies in relation to the supravaginal operations. Of course, 
this is a topic thal; is discussed quite often. I am more and more frequently doing the 
supravaginal, cauterizing the cervix, but I cannot feel that it is good judgment to leave 
the cervix unless it is in good condition. Our teaching is to leave the cervix if pos- 
sible but to remove it if the conditions warrant at the time of operation. 

There have been eight ureteral injuries by six different gynecologists, rather a 
small percentage. 

There is much discussion regarding the choice of deligation or nephrostomy. I have 
felt that nephrostomy is the better operation, having seen only one case where deliga- 
tion was tried. It is a most difficult thing to deligate a ureter even if it is as large as 
your finger and I do not think it is wise to do so if nephrostomy will be beneficial. 

I have quoted a good deal from the Work of Caulk and Fischer. I have disagreed 
with them in some respects because I have seen at autopsy that the ligatures are ab- 
sorbed more rapidly than experiments would indicate. I am quite sure that in fifteen 
or twenty days the ligatures are absorbed. 



FOREIGN BODIES LEFT IN^THE ABDjOMEN AFTER 

OPERATION'-' 


J. P. Grkenhill., M.D., Chicago, Ile. 


D uring the last three decades, there has been a remarkable improve- 
meut in the teehnic associated with abdominal operations. This ap- 
plies not only to the increase in skill and dexterity o£ surgeons but also to 
the advancement made in the problems of operating room facilities, light- 
ing equipment, instruments, anesthesia, and other factors. Because of 
the dangers to the patient of leaving foreign bodies ^Yithiu the abdomen 
and also because of the direful consequences to the surgeon of a lawsuit 
as a result of this, efforts have always been made to prevent such occur- 
rences. During the last twenty-five years many recommendations have 
been made on how to cheek up the loose armamentarium used during an 
operation. At present most hospitals have rather elaborate sj^stems for 
this purpose and the common belief is that it is an extremely rare occur- 
rence for an instrument or a sponge to he left in the abdominal cavity after 
an operation. Yet a high official in a large insurance company which pro- 
tects physicians and dentists against malpractice suits informed me that 
his company takes care of approximately one hundred suits dealing with 
foreign bodies each year. Also that about one in every fifteen suits for 
malpractice against physicians and surgeons is for a foreign body. Since 
there are many insurance companies which insure physicians against 
malpractice suits, we can only conjecture the appalling number of foreign 
bodies left in patients after operations. 

As far as I know' only three of all these hundreds of malpractice suits 
have been reported in medical literature, although more of them maj^ have 
been recorded in the medicolegal section of the Journal of the American 
Medical Association. 

The large majoritj^ of malpractice suits for foreign bodies never reach 
the courts because for obvious reasons they are settled out of court. In 
spite of this however, I found records of 68 cases of foreign bodies carried 
to the courts of the various states in this country from 1897, when the first 
case was apparently recorded, to 1925. These 68 cases represent only those 
cases which were taken to court and on which a verdict was rendered. 
Where a case was not taken to court and even where it Avas taken to court 
but no verdict Avas rendered, either because the suit Avas dropped or for 
some other reasons, it Avas not included in these 68 cases. In many of the 
cases Avhere verdicts Avere rendered, they Avere in favor of the patient. 
Even in the cases where the surgeons Airere absoh^ed from responsibility. 


• tit tlie^ Forty-FiCtli Annual Meeting" of the American Associatinn nf 

Abdominal Surgeons. French Lick Springs, Ind., September*12^ 

231 



232 


A5IERICAN JOURNAL. OF OBSTETRICS AND GYNECOLOGY 


most of them suffered incalculable harm as a result of the odious notoriety 
usually associated with such lawsuits. 

The question of guilt has not been answered by all courts in the same 
way. In answer to a query in the Journal of the American Medical -ds- 
sociation the following information was given : 

"Responsibility for allowing a surgic.al instrument or other foreign body to remain 
in the abdomen after an abdominal operation rests on the party through whose default, 
or through the default of whoso agents, it was allowed so to remain. To locate that de- 
fault on the proper party, it is ncecssarj' first, to ascertain the respective duties as- 
sumed by each of the several participants in the operation, personally and through his 
agent. Then it must bo ascertained which of such participants defaulted in the dis- 
charge of the obligations that they had assumed ■with respect to the patient, and by 
whose default the patient was as a proximate result injured. The duties assumed by 
each of the several participants in the operation must be determined according to their 
respective relations to the patient, ai-ising out of contracts, expressed or implied, or out 
of the relations between the parties independent of contracts. Such relations, so far as 
they are not fixed b3- contracts, are determinable from a study of the general customs 
relating to such operations, and of local and special customs a Icnowlcdgc of which, 
prior to the operation, is brought home to the patient. No hard and fast rule can be 
laid down for determining the division of responsibilitj' between the operating surgeon 
and the hospital. Cliaritable hospitals, however, arc in manj’ jurisdictions held to be 
free from liability to their patients, except for such injuries as may result from a failure 
on the part of the hospital to e.xercise due care and skill in selection of its agents and 
employees. ’ ’ 

In certain states ineludiug Illinois, Indiana, New York, Massachusetts 
and others, the courts hold the following point of view. Every modern 
hospital has nurses who count sponges and instimments before and after 
operations. At the request of the sui’geon they report that all the s^jonges 
and instruments are accounted for at the end of an operation. If there is 
a mistake in counting, it is due to negligence of the nurse who is in the em- 
ploy of the hospital. The surgeon is not responsible in such a case. Un- 
like charitable hosjiitals private ho-spitals are not immune in any state. 

The above discussion deals with foreign bodies, the presence of which 
sooner or later becomes known to the patient or to the jiatient’s relatives. 
In addition to these cases there is a veiy large number in which foreign 
bodies are accidentally found by surgeons who usuallj’^ make no mention 
of their discoveiy to the patient or to his or her relatives. In fact very 
few of these cases are made known to anyone except those in the operating 
room, because of the desire to protect the surgeon who performed the first 
operation. Many surgeons in conversation will reveal having removed 
one or more foreign bodies which they or others have left behind, but they 
seldom report these facts in medical literature. In support of this conten- 
tion I should like to cite the report of Wliite. This author sent inquiries 
to surgeons in all parts of Great Britain asking for unpulhslied eases of 
instruments left in the peritoneal cavity after operation. He specifically 
requested that forgotten laparotomy pads and gauze sponges be omitted 
and in spite of this he received details of 39 instrument cases. White him- 



GREENHILL: FOREIGN BODIES DEPT IN ABDOMEN 


233 


self had two cases and there were three additional specimens in the 
Mnsenm of the British College of Surgeons. In this series of 44 cases, 
eleven patients died (25 per cent). Likewise Schachner sent letters to 
many surgeons in the United States and all but four reported that they 
themselves had left one or more foreign bodies in the abdomen. 

There is still a third group of forgotten foreign bodies, namely, those in 
whieh the mishap remains unrecognized. Undoubtedly there are patients 
in whom foreign bodies have been left and who die of peritonitis or other 
causes. There is no suspicion of the true cause of the peritonitis because 
an autopsy is not performed. That such cases are not infrequent is proved 
by the relativel 3 '' large number of foreign bodies which were discovered ac- 
eidentallj’’ at postmortem examinations. 

In the literature a relatively large number of articles devoted to this subject have ap- 
peared, especially in the first decade of the present century. The most extensive papers 
with a compilation of cases are those by Neugebauer (1900), Schachner (1901), Goer- 
lich (1908), Crossen (1909), and Albitzky (1917). In remewing the literature from 
1859 to 1908 Crossen found reports of 172 sponges and 51 forceps and other articles left 
as foreign bodies after abdominal operations. In addition he found 18 cases of foreign 
body left after vaginal operations. Among the 172 sponge cases, the end-results were 
as follows: 83 patients (48.3 per cent) recovered, 53 patients (30.8 per cent) died, and 
in 36 cases (20.9 per cent), the outcome was not mentioned. Among the 50 patients 
with forceps or other instruments (in one patient two forceps had been left, hence the 
51 instruments in 50 patients) the results were as follows: 17 patients (34 per cent) 
recovered, 14 patients (28 per cent) died, and in 19 cases (38 per cent), the results were 
not stated. Hence among the entire 222 patients with foreign bodies, 100 patients (45 
per cent) recovered, 67 patients (30,2 per cent) died, and in 55 cases (24.8 per cent), 
the end-result was not stated. In this series of 222 cases, the original operation during 
which the foreign body was accidentally left, was an abdominal one in 30 cases (13.5 
per cent)f a pelvic one in 86 cases (38.7 per cent), and in 106 (48.7 per cent) cases, 
the type of operation was not listed. In 52 of the 222 cases (23.4 per cent), the foreign 
body was discovered at autopsy. 

In Albitzky ’s series 56.8 per cent of the patients were females, 3.2 per cent were 
males, and in 40 per cent, the sex was not stated. In 80.4 per cent the foreign bodies 
were left during gynecologic operations, and in 19.6 per cent during other types of 
surgical operations. In this series 48.5 per cent recovered, 23.5 per cent died, and in 
2S per cent, the outcome was unknown. In 38 per cent the foreign body was removed 
during a second operation, in 20 per cent it was expelled spontaneously, in 2.1 per cent 
it was found at autopsy and in the remaining 21 per cent there was no report as to how 
the foreign body was discovered. 

I had the unusual experience of finding three foreign bodies within 
eleven months. Brief abstracts of these cases are as follows : 

CASE REPORTS 

Case 1.— Mrs. I. B. (No. 1,043,841), aged thirty was admitted to the Cook County 
Hospital on January 4, 1928 because she had a persistent, purulent discharge from an 
abdominal wound, chills, fever, nausea and vomiting and had lost 25 pounds in the last 
five weeks. The family history was negative. The past history was unimportant ex- 
cept for two operations performed at another local hospital ten weeks and five weeks re- 
spectively before admission to the Cook County Hospital. A posterior colpotomy had 



234 


AJIERICAN JOURNAL OP OBSTETRICS AND GYNECOLOOr 


been done the first time. Five weeks later a laparotomy was performed and both tubes 
and ovaries were removed. (Inquiry at the hospital where the operations were per- 
formed elicited tlic information that both tubes and ovaries liad been removed but not 
the uterus.) Immediately following the laparotomy, a purulent discharge escaped both 
from the abdominal incision and from eolpotomy wound. Then the patient had chills, 
fever, and anorexia, and she vomited most of her food. She left the hospital in this 
condition. The general phy.sie.-il e.xamination on admission to the Cook County Hospital 
revealed no abnormalities other than extensive emaciation, marked pallor, and a foul 
odor. The temperature was l(kl.()° F., the pulse wa.s lOS per minute and respirations 
were 20 to the minute. The blood pressure w;is 110/70, The red blood coll count was 
1,180,000, the hemoglobin was 30 per cent, the white blood cell count was 4,400 of which 
02 per cent were jiolymorphonuclear leucocytes, 24 per cent were large lymphocytes, 
10 per cent were small lymphocytes, and 4 per cent wore myelocytes. 

Abdominal e.xamiiiation revealed a low inidlinc scar, well-healed, except at the lower 
end where there was a sinus. From this sinus foul-smelling pus escaped. Vaginal ex- 
amination was made with difiiculty because the introitus and the vagina were very tight. 
The cervix was small and hard. Behind the ccrvi.x, tlie eolpotomy ojiening could be felt 
and through it, the same typo of pus escaped as came out of the abdominal sinus. The 
body of the uterus could not be outlined but the entire pelvis was found to be indurated. 
The diagnosis made w.as pelvic iibsccss due to a foreign body or tuberculosis with sec- 
ondtiry infection. Tlie Wassormann reaction was negative. An x-ray picture was t.aken 
and a shadow of a str.aight pin was found anterior to the right half of the sacrum. 
Eoentgen ray pictures were repeated twice on different days and the straight pin was 
found in the same jiosition each time. A lateral projection picture showed the pin to be 
at the level of the sacral promontory. 

Tile patient refused to be operated upon and left the hospital. We could not trace 
her. 

The straight pin had probably been accidentally enclosed in a package of gauze 
pads or sponges when these were wrapped or the pin was dropped when a package of 
gauze pads was opened during the operation. 

Case 2. — Mrs. L. H., aged thirty, was admitted to the Cook County Hospital on 
May 24, 1928 because of pain in the lower abdomen. Slie had been inaiTied ten years 
but had never been pregnant. The family and past histories were unessential except 
for an appendectomy performed in Ohio three years before admission. The patient 
felt entirely well until six weeks before the present admission to the hospital. From 
that time on she experienced a constant, dull pain in the lower abdomen. This became 
progressively more severe. The pain was frequently associated with nausea but vomit- 
ing never occurred. During all this time there was a profuse foul vaginal discharge 


and constipation. 

The general physical examination was entirely negative, except for a temperature 
of 99.8° F. The red blood cell count was 3,950,000, the hemoglobin SO per cent and the 
white blood cell count was 8,900, On abdominal examination tenderness was elicited 
suprapubically and in the left iliac fossa. Ho masses were palpable. Vaginal examina- 
tion revealed hypertrophied labia minora. There was no cystocele or rcctocele. The 
anterior lip of the cervix was hypertrophied, smooth and not lacerated. The fundus of 
the uterus was enlarged, very hard, anteflexed and moderately movable. When the uter- 
us was pushed backward the patient complained of great pain. The right tube was en- 
larged and tender. The left adnexa were converted into a very tender cystic, adherent 
mass. In addition to these masses there was a round, exquisitely tender, slightly ir- 
regular mass in the culdesac. The diagnosis made was fibrosis uteri; left tuboo\arian 
abscess, right salpingitis and prolapse of the cystic right ovary. After the patient s 
temperature dropped to normal and remained so for a few days a laparotomj was per 



GREENHILL: FOREIGN BODIES LEFT IN ABDOMEN 


235 


formed. Both tubes were enlarged and inflamed. A defundation of the uterus was 
performed and both tubes and the left ovarj' were removed. The right ovary was found 
to be in its normal position and in good condition. The very tender cystic mass which 
had been felt in the culdesac was easily shelled out and when opened proved to be a 
gauze sponge surrounded by a thick capsule of fibrous tissue. Convalescence was un- 
eventful and the patient left the liospital on the eleventli postoperative day. The 
sponge had been left in the abdomen three years previously and had not given rise to 
any symptoms until perhaps six weeks before I saw her. Even these symptoms were 
most likely due to the salpingitis rather than to the gauze sponge which was well en- 
capsulated and fairly clean. 

Case 3. — Mrs. A. K. (No. 68137), aged thirty-seven was admitted to the Chicago 
Lying-in Hospital on December 9, 1928. She had had two cesarean sections performed 
by two different obstetricians, one thirjteen years and the other tei^years before admis- 
sion. She was sterilized at the time of the second operation. The menstrual history 
was negative and her last menses had begun November 27. Her complaint was pain in 
the abdomen. The general examination was negative. There were two incisions in the 
lower half of the abdomen which was distended by a hard, somewhat tender mass. The 
latter apparently rose out of the pelvis and was adherent to the abdominal scars. Vag- 
inal examination revealed a nulliparous outlet. The cervix was long, hard, smooth and 
way up high behind the S 3 ’mph}’sis and on the left side of the vagina. The fundus of 
tlie uterus was enlarged to the size of a five months ’ pregnancj', hard, and adherent to 
the abdominal wall. To the left of the uterus was a soft, slightly irregular cystic 
mass approximately S bj' 10 cm. in diameter. This mass was verj' tender. The diag- 
nosis made was fibroid uterus and left ovarian cj'st. However, because the patient had 
not menstruated from March to November, I wished to rule out a pregnancy such as a 
missed abortion. A roentgen raj’ picture w'as taken and much to mj’ amazement a 
shadow of a large curved needle was seen on the right side. There were no fetal struc? 
tures to be seen. An operation w’as performed on December 14, 1928 and great diffi- 
culty was encountered because the large fibroid uterus was firmly attached to the ab- 
dominal wall, and there were very dense adhesions between the uterus and the adnexa. 
The fibroid uterus and the adnexa including the ovarian cj’st on the left side were re- 
moved. A search was then made for the needle, and this was found entirely buried be- 
tween the folds of the mesoappendix. The needle was removed and then the appendix 
was amputated. There appeared to be. almost no reaction around the needle for it was 
perfectly clean. Convalescence was disturbed bj' a wound infection. The patient left 
the hospital on the seventeenth daj’ following operation. The needle had almost cer- 
tainly been left in the abdomen at the time of the first operation because the second 
operator informed me that he had never used such large curved needles at anj’ time 
in his career. 

Review op the Literature 

I have reviewed the literature from 1908 (Crosseii’s comprehensive re- 
port) to January, 1932, and found that 109 cases of foreign bodies in the 
abdomen have been reported in American, British, German, French, 
Italian, Spanish, and Russian joui’iials. There were a few eases however, 
whieh had to be omitted because I could not secure the original journals. 

Only those foreign bodies are listed which Avere left in or gained access 
to the peritoneal ea^nty. With the exception of six eases all the original 
operations Avere laparotomies. The exceptions Avere tAvo herniotomies, a 
colpotomy, a sacral operation, a vaginal pack for abortion and a plastic 
• operation for fat in the abdominal Avail. 



236 


ASIERICAlsr JOURNAL OP OBSTETRICS AND GYNECOLOGY 


An analysis of the tabnlatecl eases reveals the following types of foreign 
bodies : 


Gauze 

Artery forceps 
Needle 
Rubber tube 
Retractor 
Towel clip 
Glass tube 
Glass rod 
Straight pin 
Thick thread 


I'S (52.2 per cent) 
3S (34.9 per cent) 
4 

0 
2 

1 
1 
1 
1 
1 


109 

The foreign body was recovered at a subsequent operation in 87 cases 
(80 per cent), it was expelled .spontaneously fifteen times (13,8 per 
cent), it was discovered at autopsy in 5 eases (4.6 per cent), and two pa- 
tients are still carrying around their foreign bodies (pin and glass tube 
respectively) . 

In the 87 cases where the foreign body Avas removed by operative pro- 
cedures, the means of access ivere as follows; 


Laparotomy 

The bladder 

The vagina 

Bier 's suction pump 

A fistula in tlic wound 


75 

4 

3 

D 

O 


87 


In 15 cases the foreign body was expelled spontaneously as follows : 


Through the rectum 7 

Through the wound 5 

Through the urethra 1 

Through the vagina 1 

Coughed up 1 


15 

The ultimate results in the 109 eases Avere as folloAvs : 


Recovered 

Died 

Unknown 

Still in the patient 


76 (69.7 per cent) 
19 (17.4 per cent) 
12 (11.0 per cent) 
2 ( 1.9 per cent) 


109 

Of the 75 patients avIio had subsequent abdominal operations for the re- 
moAml of the foreign body, 14 or 18.7 per cent died. Among the entire 97 
patients in Avhom the results are knoAvn, 19 or 19.6 per cent died as the re- 
sult of the foreign body, hence these two death rates are almost identical. 
The length of time the foreign body remained in the abdominal cavity 
Amried considerabljL The longest interval recorded aaus tiventy-four 
years. LikcAvise the size of the foreign body ranged AAuthin wide limits and 
in one ease a laparotomj'’ pad 72 cm! long had been OA^ei’looked during an 
operation for a tAvisted ovarian cyst during pregnancy. 



GREENHILL : FOREIGN BODIES LEFT IN ABDOMEN 


237 


ETIOLOGY 

One or more factors may be responsible for leaving a foreign body in 
the abdomen. Carelessness on the part of the operator and his assistants 
■undoubtedly accounts for some cases. However unreliability of the nurses 
who are in charge of counting sponges and instruments before and after 
operations is the most important factor. Not infrequently the introduc- 
tion of extra, uncounted sponges or instruments during an operation is the 
cause of this accident. In some eases the fault lies in a poorly administered 
anesthestie because of which there is considerable retching, expulsion of 
the intestines to the outside of the wound, rapid, forcible attempts to re- 
place and hold the intestines back, undue bleeding, haste to complete the 
operation and other disconcerting occurrences. In a few cases the patient 
goes into shock and the operator hurries to close up the abdomen without 
proper inspection of the field of operation. Poor light and untrained as- 
sistants, poor exposure of the field of operation, the use of an unneces- 
sarily large number of instruments especially small ones and failure to 
remove all excess fluids such as serum, blood, and pus are factors in some 
cases. 

PATHOLOGY 

In nearly all cases there is some evidence of old or recent peritonitis. 
The foreign body is surrounded by the omentum and neai’by organs which 
attempt to encapsulate it. Sooner or later however, in most eases, the 
foreign body exerts pressure and forces an opening into a hollow organ 
with or without associated signs and symptoms. After this in some cases 
there is spontaneous expulsion of the foreign body to the exterior but in 
most eases operative interference is required to remove the offender. 

SYMPTOMS 

During the first few da5"s after a foreign body has been left in the ab- 
domen there are usually no symptoms by means of which attention would 
be drawn to this accident. Rarely a patient may describe the sensation 
of something moving around in the abdominal cavity. A clean smooth in- 
strument is less likely to cause peritonitis than a gauze sponge or pad 
saturated with blood or pus. After a few days or weeks symptoms gen- 
erally arise and they are usually the result of peritonitis. In most eases, 
the omentum rapidly demonstrates its protective mechanism by surround- 
ing the foreign body and shutting it off from the organs in the peritoneal 
cavity. If this does not occiu and sometimes also even when this does take 
place, serious disturbances arise such as intense pain some'where in the 
abdomen, signs and ss’^mptoms of ileus, bladder disturbances, rectal tenes- 
mus, abscess formation, the development of a tumor or a fistula, or the pro- 
trusion of part of the foreign body through the wound, the rectum or the 
bladder. 



238 


A5IERICAK JOURNAL, OF OBSTETRICS AND GYNECOLOGr 


DUVGNOSIS 

If a patient has an nnnsual amount of jiain or strange abdominal symp- 
toms soon after a laparotomy, a foreign body should be thought of. Care- 
ful abdominal, vaginal (in women), and rectal examinations should be 
made with the patient lying in various positions and even sitting up. 
Roentgen ray pictures should be taken including both anteroposterior and 
lateral views. Instruments will always be revealed by this means but not 
gauze, unless it has been specially prepared for this purpose or unless it 
has a piece of metal attached to it. If a long time has elapsed since the 
operation and the patient has bladder symptoms, cystoscopy is indicated. 
If there arc rectal .symptoms, both a digital and a proctoscopic examina- 
tion should be made before taking the x-ray pictures. If there is a sinus, 
which persists in spite of treatment, a foi-eign body should be considered. 
A large flexible probe should be inserted into the sinus in the hope of en- 
countering an instrument, in which case, a metallic sound will be elicited. 
Lipiodol or other opaque substance should be in.iected into the sinus and 
roentgen-ray pictures taken. If gauze is in contact with the sinus, the 
opaque substance Avill saturate it thereby enabling one to detect the gauze 
in the x-ray pictures. If a protuberance is felt in an abdominal sear it is 
advisable to out down to the mass to see what it is. If a mass is felt in the 
culdesac of a woman, a eol]DOtomy should be performed. In cases where 
ileus is present a laparotomy is necessar.v ; but even where the symptoms 
are not alarming it is occasionally advisable to jierform an exploratory ab- 
dominal operation to seek the cause of vague signs and symptoms which 
follow a laparotomy. 

PROGNOSIS 

If a foreign body is removed immediately after it is left in the abdomen, 
the outlook is excellent. Even if the foreign body is removed within a 
few days after it is left, the prognosis is very good. The sooner the second 
operation is performed after the first one, the easier the second operation 
and the better the results. In eases where the foreign body has been in 
the abdomen for many .years, adhesions make the second operation a se- 
rious task. The fact that there was a death rate of 17.6 per cent among the 
patients who were operated ujion in the series I collected for recent years, 
is proof of the x-isk to which a patient is subjected when a foreign body is 
left in the abdomen. 

PROPHYLAXIS 

It is needless to emphasize that all the sponges, lapai’otomy pads, dress- 
ings, instruments, drains, tubes and other paraphernalia which are pre- 
pared for use during an operation must be most carefull.v checked up both 
hefore the operation is begun and before the peritoneum is closed. An- 
other cheek up should be made while the skin is being sutured. If any- 
thing is i-eported to be missing, the opei’ator must carefully scrutinize the 



GREENHIIiL: FOREIGN BODIES LEFT IN ABDOMEN 


239 


abdominal cavity while further search is being made by the nurses. Dur- 
ing all operations there should be good light, and sulBcient exposure of the 
field of operation. The anesthetic should be administered by a trained 
anesthetist or by someone undex* the supervision of a shilled anesthetist. 
For most laparotomies it is safest to have two assistants. All fluids such as 
serum, blood, and pus should be removed from the peritoneal caAdty and 
the ixeritoneum should be left as clean as possible. Blood vessels, certainly 
the large ones and the moderatelj’- sized ones should be clamped or ligated 
before being cut across to avoid undue bleeding. Long instruments are 
always preferable to short ones and the fewer the instruments used the 
safer it is for the patient. It is much better to apply ligatures directly to 
large vessels and ligaments rather thaix clamps followed by ligatures. If 
clamps are used, they should be removed and replaced with ligatures as 
soon as possible. No gauze sponge, laparotomy pad, or rubber pad should 
be inserted into the abdominal cavity xvithout having some kind of metal 
attached to it. Even ivlieu the gauze is specially prepared uuth a sub- 
stance which will show itself on roentgen ray plates, it is still advisable to 
attach metal i-ings, clips or instruments to these pieces of gauze. If onlj’- 
one long piece of gauze is used throughout the operation, the surgeon 
should be certain that the distal end of it is pinned or tied to its container 
and the latter in tui'n attached to the sheet which covers tlie patient. No 
piece of gauze, rubber tissue or di’ain should ever be cut off without the 
surgeon knowing exactly what disposition is made of the unused pieces. 
Before the peritoneum is sutured, the surgeon should invariably himself 
carefully search the peritoneal cavity for foreign substances and then ask 
the nurses out loud whether all the sponges, laparotomy pads, instruments 
and other appurtenances are accounted for. He should not suture the 
peritoneum until he receives an affirmative answer. The personal search 
and question and answer may prove helpful in a lawsuit. 

TREATMENT 

If, while the patient is still in the operating room, the surgeon is in- 
formed by a nurse that she is sure something is missing, the abdomen 
should be opened vdthout delay and a search made. If, during the first 
few daj’s after an operation, there is good reason to believe that a foreign 
body has been left in the abdomen and cei’tainly if an x-i’ay pictui*e dem- 
onstrates it, a laparotomy should be done without delay unless the general 
condition of the patient is so poor that a second operation is contraindi- 
cated. There is no serious risk in waiting a few days to improve the pa- 
tient’s condition in such a case. In late cases, the treatment will depend 
xpon the cireiimstances which are present. If there is a persistent sinus, 
lipiodol injection followed by x-ray pictures may reveal the source of the 
sinus If It IS a foreign body, it should be removed. If a tumor mass is 
ouiid protruding through the abdominal wound, into the vagina or into 



240 


AJIERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


tlie rectum, tlie mass should he removed by incising these respective areas. 
If the foreign body is in the bladder it may sometimes he removed through 
the urethra, else the bladder will have to be incised. Foreign bodies dis- 
covered by roentgen ray pictures long after an operation was performed 
and which cannot he removed by a simple incision must he removed by a 
laparotomy as soon as the diagnosis is made. Even if a foreign body is ac- 
cidentally discovered in a patient Avho has no abnormal sjrmptoms, it 
should he removed because there is a great risk in leaving it in the 
abdomen. 

CONCLUSIONS 

In spite of the relativel}’- few ease reports in the literature of foreign 
bodies left in the abdomen after operation, an appalling number of such 
cases occur each year. "While in an occasional case, the condition seems 
to he unavoidable, in the vast majority of cases it is due to negligence of 
either the surgeon or more particularly a nurse. The condition is serious 
because in the present series of 109 cases which I collected, including three 
eases which came under my o\\m observation, there was a mortality of at 
least 17.4 per cent. IMost of the foreign bodies left in the abdomen were 
gauze sponges or pads (52.2 per cent) and next in frequency were artery 
forceps (34,9 per cent). The foreign bodies were detected during a sub- 
sequent operation in 80 per cent of the cases, they were expelled spon- 
taneously in 13.8 per cent, and they were discovered accidentally at au- 
topsy in 4.6 per cent. In this paper the etiology, pathology, symptoma- 
tology, prognosis, prophylaxis and treatment of foreign bodies are 
discussed. 

185 North Wabash Avenue. 

ABSTEACT OP DISCUSSION 

DE. JAMES W. KENNEDY, Philadelphia, Pa. — 'We give as a solution for the 
problem the simplest possible technic of •which the surgeon may become the master. 
We 'work -with three gauze towels and three gauze sponges and one assistant. This 
very small number of gauze towels and sponges is placed in two basins and it is easy 
for the surgeon to inspect the three gauze towels and sponges in each basin before 
and after the operation. No other piece of gauze is ever permitted to remain within 
the abdominal cavity. 



SIGMOIDOUTERINB AND VESICOUTERINE FISTULA AS A 
COMPLICATION OP CHILDBIRTH*'^ 

AValter C. G. Kirchner, M.D., St. Louis, Mo. 

A lthough cases exlilbiting uterine fistulas in association with child- 
birth occur very rarely, nevertheless, they deserve our earnest con- 
sideration, not only on account of the unfortunate plight in Avhich the 
patient finds herself and the difficulty of treatment, but also because of 
the tendency of the eases at times to assume a medicolegal aspect. 

Uterine fistulas have occurred as a result of accident or in the course 
■of instrumental delivery, and also as a sequence of diseases involving 
the uterus, intestines, bladder or pelvic organs. However, it is with the 
idea of emphasizing the belief that intestinouterine and vesicouterine fis- 
tulas may occur spontaneously in the course of or as a result of a difficult 
labor, that I have been encouraged to present this paper. The problems 
as to the cause and the treatment of uterine fistulas associated with child- 
birth were brought home to me when cases of sigmoidouterine and vesico- 
uterine fistulas were referred for treatment and operation, and an account 
■of these cases may serve as a basis of argument and discussion. Brief 
recitals of the histories of these eases and comments on the reports of 
■other cases are herewith reported. 


SIGMOIDOUTERINE FISTULA 


Case 1. — The patient, Mrs. B., age thirty-six, of average stature and weiglit, was 
nasually in good health and was able to attend to her houseliold duties. Only meager 
information was obtainable concerning her first pregnancy; however, it was stated 
that the delivery of the child was difficult, forceps were used, and that the child was 
dead or died soon after birth. The patient became pregnant a second time, and when 
In labor a physician vfas called who found it necessary to resort to instrumental de- 
livery. Craniotomy was performed and the uterus was emptied of its contents. The 
patient recovered and there were no unusual complications following the extraction of 
fhe child. 

On March 16, 1913, four years after the birth of the second child, the patient, in 
labor for the third time, sent for her former physician. On arriving at the patient’s 
home he learned that but little progress had been made, that the pains were ineffectual, 
nnd that the patient had become quite exhausted. At the examination it was found 
that the presenting head was high in the pelvis and, presumably, the bag of -waters had 
ruptured some time previously, so that, in effect he was confronted with a dry labor. 
Instruments were employed to assist in the rotation of the head, and even after re- 
peated application of forceps, the patient being anesthetized, it was found impossible 
to deliver the child. A consultant was called, and, the child being dead, craniotomy 
was performed. It was stated that this latter procedure was carefully done and that 
no undue injury was done to the soft parts while this operation was in progress. The 
patient recovered nicely from this operation, and on the following day, March 17, her 


•Read at the Forty-Fifth Annual Meeting- of the Americai 
lemem“r’l?T932°^°®‘®‘® Abdominal Surgeons, French 


Association of Ob- 
Lick Springs, Ind., 


241 



242 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


condition was very good. On !March IS, the patient was feeling well and, without any 
warning, there was si sudden “explosion” aJid a considerable quantity of gas was 
passed through the vagina. Subsequently fecal matter was also passed through the 
vagina. On the two following days the condition remained unchanged. The patient 
had no great discomfort, and at no time was the temperature over 100° P. 

A vaginal examination revealed that the discharge of focal matter came from the 
cervix, though the location of the opening in the bowel was not discovered. 

A proctologic examination was made and it was believed that the opening in the 
bowel 'was high up in the rectum. Practically all of the fecal matter was discharged 
through the vagina, very little if anj' stool passing through the anus. I saw the pa- 
tient at the hospital and the following condition was found upon e.vamination: 

There was a fecal discharge from the vagina. All wounds of the vagina, such as 
follow delivery, were healed. Through the speculum it was noted that the external os 
was open, moderately lacerated, and that fecal matter c.'ime through the cervical canal. 
The cervix was adherent at the posterior portion. There was no pusj neither were 
there signs of intlammation. By digital examination the uterus was found slightly 
enlarged, adherent postcriorl 3 ' at the cervical portion, though the fundus was sljghth' 
movable. The adnexa wore free. The rectum was examined digitallj' and with the 
proctoscope, and even with the use of the sigmoidoscope I was unable to find the open- 
ing which communicated with the uterus. TJic character of the fecal matter indicated 
a fistula of the large bowel, and a tentative diagnosis of sigmoidouterine fistula was 
made and an operation for the cure or relief of the condition was recommended. 

Opos-aiion . — It was decided to attack the fistula by the vaginal route, and bj' lapa- 
rotomy if neccssarj’. Ether .anesthesia was administered. Through the posterior 
vaginal fold a dissection was made to expose the posterior wall of the cervix. The dis- 
section was carried up as far as the fistulous tract which was loosened up and made as 
free as possible on all sides. The opening through the posterior vaginal w.all also gave 
access to the euldesac of Douglas, and permitted digital examination of the abdominal 
portion of the fistula. Laparotomy was decided upon after a Fenger probe was in- 
serted through the fistula into the intestine. 

Laparotosinj . — Left rectus incision. The uterus was somewhat enlarged and about 
the size of a man 's fist. Tubes, ovaries and broad ligaments were normal but flaccid. 
The sigmoid flexure of the colon at a point .a little below the middle portion was adher- 
ent to the uterus. There was no pelvic peritonitis and there were no adhesions aside 
from those taking part in the fistula. The condition resembled a lateral anastomosis- 
of the sigmoid with the uterus, both loops of the bowel being free. The loop of sig- 
moid was dissected free from the lower portion of the uterus, and the opening in the 
bowel was closed with a double row' of sutures. The opening in the uterus involved, 
mostlj' the cervical portion, and this was closed, through the laparotomy opening, by 
means of deep and superficial sutures. A cigarette drain leading into the vagina was 
placed in the euldesac. There being no special complications, the abdominal wound 
was closed in laj-ers. The patient was given the usual postoperative care. 

Within one month all wounds were healed. The uterus was of nearlj' normal size, 
and movable. The cervix and external os were large and thei'e was a sUght thickening 
of the posterior part of the cervix where the repair had been made. Bowel movements 
and defecation were normal and painless. Menstruation was normal, and five j-ears 
after the operation she was in good health. 

A review of the literature revealed several additional cases which are 
briefly narrated for the sake of comparison. 

Petit“ had collected up to 1882, 18 cases of intestinouterine fistula which occurred 
as complications of pregnanej', but the manner in which these fistulas were produced 
was not alw'ays satisfactorily explained. Loenne^' reports a case in which the woniait 



KIRCHNER: eistula 


243 


■ivas in labor for nearly tn’O days, tbe bag of waters rupturing at the end of the first 
day. Wben the pain grew less effeetive, the physician finally applied high forceps. A 
living child was delivered. On the third day there were signs of rafection, the patient 
later becoming septic. There was pus in the stools. The patient died and at the 
autopsy two perforations were found in the eeeum as well as a perforation in the pos- 
terior wall of the uterus. There were feces in the pelvis and a widespread peritonitis. 
He quoted Pranque’s case which was similar, there being likewise a perforation in the 
posterior wall of the uterus near the eervLx. 

In a case reported by Le Jemtel” a phj’sieian had been called in one and a half 
months after delivery when signs of infection had developed. He performed curettage 
and there was some improvement for a few days. The fever returned and shortly 
thereafter there was a discharge of feces through the cervix. The rectal opening closed 
spontaneously. 

Graves” reported a ease in which after forceps delivery there was a perforation of 
the fundus of the uterus and a prolapse of the small bowel into the vagina. The sec- 
tion of prolapsed bowel had been removed, but there was discharge of feces through 
tlie uterus and vagina. The integrity of the intestinal tract was reestablished and the 
patient made a satisfactory recovery. 

Noeeker” reported a ease in which carcinoma of the cervi.x had been suspected and 
radium treatment had been instituted. Pour months later the patient began to pass 
intestinal contents through the vagina. It was found that there was a perforation of 
the uterus which communicated with the lumen of the sigmoid and also with small 
bowel. A panhj'sterectomy was done. 

Peraire” reports a ease of intestinoutero-appendicular fistula wbich occurred subse- 
quent to curettage, the latter being performed for a severe infection after a long and 
hard labor. Laparotomy was performed. The postoperative course was normal. 

VESICOUTERINE FISTULA 

Case 2. — The patient, hirs. T., first presented herself for treatment in March, 1924, 
at which time she complained of bleeding from the rectum. She had the usual dis- 
eases of childhood. When she was five years old she had prolapse of the rectum for 
which condition an operation was performed when she was 15 years old. Menstruation 
which began during her seventeenth year has abvays been normal. She married at the 
age of 21 and has had two children. At the last childbirth there was a perineal lacera- 
tion the repair of which had been deferred. Although the patient’s general health 
was excellent, it was found upon examination that the bleeding from the bowel was due 
to the presence of a large number of rectal polyps. An operation was performed by 
the writer for the relief of this condition, and some seventy-five polyps of various sizes 
were removed hy means of the actual cautery. The patient remained in good health 
but three years later a pol 3 "p 5 cm. in length rvas removed from the lower portion of 
the sigmoid. 

Ten years after the birth of her last child the patient became pregnant for the third 
time, and the family physician was directed to take charge of the ease. The patient 
worried a great deal while eanying the child and toward the latter months of preg- 
nancy developed pronounced symptoms of hj'perthj'roidism. The abdominal muscles 
were greatly relaxed, and the patient having refused to wear an abdominal support, 
the abdomen became pendulous and the uterus assumed a position of arrtiflexiqn and 
sagged forward and doivnward. The familj- physician was thus confronted with serious 
complications at the time of delivery and the labor being tedious and difficult 1 was 
sent for in an emergency to take charge of the delivery. 

Upon arrival at the patient’s home 1 found that the patient was in a highly nervous 
state, the face was suffused, red and swollen, the heart action was rapid, there was a 
imtral murmur, the pulse rate 140 to 160 per minute, the patient was making frantic 



244 


AJIEKICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


physical efforts to bring about the expulsion of the child, the bag of waters had rup- 
tured, the uterine contractions were active and forceful, the cervix was edcm.atous and. 
presented itself at the vulva and the head was firmly wedged in the pelvis. 

A general anesthetic was administered and it was with great difficulty that the cer- 
rix was replaced behind the pubes to permit of proper dilatation and delivery. Low 
forceps were used to assist in the dislodgmeiit and rotation of the head, and firm but 
careful traction was required to effect the delivery of the child. At no time did the 
instrument come in contact with any portion of the uterus or vagina adjacent to the 
bladder. An L.O.A. delivery of a large child was effected after some difficulty, how- 
ever, the child was dead when born. A careful inspection of the passage was made 



Pig. 1. — Pyelogram showing also loop of bougie inserted into bladder through vesico- 
uterine fistula and emerging through vagina. 

and there was no injury to the cervix or vagina which was apparent, nor laceration re- 
quiring repair. 

The postpartum handling of the patient was left to the care of the attending physi- 
cian and the course for the first three days was normal. On the fourth day the pa- 
tient began to have difficulty in urination, and the bladder becoming distended, it was- 
necessary to resort to catheterization. The bladder was catheterized daily and on the- 
tenth da)"^ it became apparent that urine was coming from the vagina. By careful 
tests it was demonstrated that the urine was coming through the cervix. A retention, 
catheter was placed in the bladder, and it was hoped that by keeping the bladder in a 
healthy condition and avoiding distention spontaneous closure of the fistula would take- 
place. For two and a half months after delivery the patient received treatments di- 
rected to the cure of the vesicouterine fistula. "Various solutions and injections were- 
used without success and operative procedure for the cure of the fistula was advised. 


kirchner: fistula 


245 


The patient was referred to Dr. H. L. Custer for cystoscopic examination. About 
one-third the distance between the ureteral orifices, on the left and slightly below the 
interureteral fold, the opening of the fistula could be seen. A No. 3 F ureteral x-ray 
bougie was passed through the fistulous opening in the bladder, and the tip coming out 
through the vagina, it was ascertained that the fistula communicated with the cavity 
of the uterus. No. 5 F x-ray ureteral catheters were also passed into each ureter. 
Pyelograms and x-ray examinations showed both hidnej's to be normal in size and posi- 
tion, and that low down in the bladder the small loop of the opaque catheter occupies 
the position of the vesicouterine fistula (Fig. 1). 

Operation . — ^A bougie haring been passed through the vesicouterine fistula as a 
guide, the patient was placed under general anesthesia. An ample transverse incision 
which included the outer layers, was made in the upper portion of the vagina and an- 
terior to the cervix. With care and patience a wide dissection was made and the blad- 
der was separated from the vagina and cervix as far as the fistulous tract. With the 
bougie in position, the fistulous tract was isolated and made free. It was necessary 
to incise the cervix longitudinally in order to remove the tract. The fistula entered 
the uterus just internal to the internal os of the cervix. Special effort was made to 
mobilize the bladder as extensively as advisable. The bougie having been removed, 
the fistula was tied off close to the bladder and removed. Fine catgut sutures were 
used for the mucosa in reinforcing the ligation. The laj'ers of the bladder in the re- 
gion of the fistula were deficient in parts, and extensive and tedious suturing was re- 
quired in order to give proper support and protection to the bladder. Fine chromic 
catgut as continuous and interrupted sutures were used for this purpose, and special 
effort was made to avoid tension or strain on the sutures. It was onlj' by adequate 
mobilization of the bladder that proper suturing could be accomplished. The uterus 
and cervix were repaired by suturing, bearing in mind the restoration of the cervical 
canal. The cervix, which had been badly lacerated by the previous childbirths, and 
also flaps of the vaginal wall were utilized in giving support and protection to the 
denuded portion of the bladder. After the operation for repair, which was tedious, 
painstaking and consumed much time was completed, a good-sized retention catheter 
was placed in the bladder and secured by means of strips of adhesive plaster. A small 
catheter was inserted well up into the vagina and this was also secured to the outer 
parts by means of adhesive plaster. Through this catheter a small amount of mercuro- 
chrome solution was instilled into the vagina. The patient, though somewhat ex- 
hausted by the duration of the operation, was returned to the bed in a satisfactory con- 
dition. 

Postoperative Course . — For the first three days following the operation the tempera- 
ture was elevated but after the fourth day the course was uneventful. 

The free end of the retention catheter which was secured in the bladder was placed 
in a sterilized urinal or bottle and continuous catheterization being thus provided for, 
the bladder was kept empty, and the slightest tension was thus relieved. 'At regular 
intervals small quantities of argyrol were instilled into the bladder through the reten- 
tion catheter. In the same manner mercurochrome solution was instilled into the 
vagina through the catheter which had been secured in the vagina. No special pads 
or drMsings were placed over the vulva. The requirements for the postoperative 
handling though exacting were simple and no special nursing was required. At the 
end of the second week a quantity of argyrol solution was allowed to remain in the 
bladder, and it was definitely determined that there was no leakage into the vagina. 
The vaginal wounds had also shown satisfactory heaUng. By plugging the end of the 
retention catheter, urine was permitted to remain in the bladder. At the beginning of 
this procedure the stopper was removed each hour and the interval was graduallv in- 
cronsGd to tlirGo hours and longer. 

In the meantime the patient was permitted to get out of bed, the catheter still re- 



246 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOOr 


inaining in the bladder. The patient left the hospital at the end of the third week at 
which time there was no leakage and the bladder liad been tested to hold more than 
ten ounces of urine. A satisfactory and complete cure of the vesicouterine fistula was 
accomplished. 

While a review of the literature has shown that the occurrenee of ves- 
icouterine fistula is rare, nevertheless, it is important that this condition 
be borne in mind as one of the complications associated with childljirth. 

Conaway” reported a case of vesicouterovaginal fistula and rectovaginal fistula 
which followed the delivery of a seven pound baby. Forceps were used and a slight 
laceration of the pelvic floor was promptly repaired. A few days later the patient no- 
ticed that she was unable to urinate and that the urine dribbled almost constantly and 
there was an odor of fecal matter about the vagina. Examination disclosed a vesico- 
uterovaginal and a rectovaginal fistula. An operation was pcrfornied and a complete 
cure of both fistulas was established. 

Luke“ was able to cure a case of uterovesical fistula by “liystcro-ostio-cleisis.” 

Rubins” reported a case of uterovesical fistul.a that had resulted after childbirth 
where there was apparently much sloughing of tissue. The woiiian subsequently be- 
came pregnant and the complications which resulted during the seventh month of gesta- 
tion were such as to cause a septicemia from which the patient died. 

A case of spontaneous healing in a vesicouterine fistula following labor was reported 
by Sims.” The patient had been in labor for si.xty hours, the meinbrane had ruptured 
and an ampule of pituitary extract had been administered which gave rise to intense 
pain. Version was resorted to and an 8 pound 14 ounce baby was delivered. On the 
morning of the fifth day the patient complained of inability to liold the urine. On 
testing the bladder with a solution of methylene blue it was found that a small stream 
of the solution came from the cervical os. Following catheterization and irrigation 
of the bladder, a silver iodide preparation was instilled, and four weeks later the fistula 
was healed. 

In a presentation of the subject of bladder fistulas Schmitz” narrates a case of vesico- 
uterine fistula that had resulted from a violent curettage when the uterus was in a sep- 
tic condition. At operation the bladder was dissected from an elongated wound in the 
body of the uterus. Healing without leakage took place. Hess” reported a case of 
unilateral fused kidney with uterovesical fistula which latter condition had developed 
shortly after delivery. 

From a review of the literature it is evident that intestinouterine and 
vesicouterine fistulas may occur spontaneously and also as the result of 
trauma. The fistulas may he associated Avith (a) the nonpregnant uterus 
or with the uterus unassociated Avith active labor at term, or also (b) AAuth 
the pregnant uterus at term. 

In the first instance the causative factors may operate from the uterus 
to the intestine or bladder, or the process may originate in the intestine 
or bladder and proceed and inA'ohm the uterus. Trauma of the uterus 
such as may be caused bj^ the curette or other instruments, diseases and 
inflammations of the uterus, namelj'' cancer and tuberculosis, and also 
processes folloAving in the course of x-ray treatments ; inflammatory dis- 
eases of the boAvel and bladder, and other diseases of the boAvel and blad- 
der such as cancer and tuberculosis, any of the conditions enumerated 
may be factors in the production of intestinouterine or A’-esicouterine 
fistula. 



kirchner: fistula 


247 


In association with pregnancj' at or near term, these fistulas maj’’ be 
the result o£ perforation of the uterus due to instrumentation such as 
might occur with forceps deliverj^, craniotomy, curettage, etc., or to per- 
foration of the uterus following a difficult spontaneous delivery. Perfo- 
ration of spontaneous origin may be the result of a prolonged labor with 
impaction of the head of the child against the promontory of the sacrum 
in which instance the bowel may be interposed between the uterus and 
the promontory, or against the symphysis pubes with interposition of 
the bladder. 

It may be observed that in many of the cases associated with pregnancy, 
the complication has occurred in multipara, that the child was large and 
Avell developed and often above ai^erage size, that usually the bead pre- 
sented, and that there was often some modification of the normal factors 
which are present and which function during the descent and rotation 
of the head. These factors may be influenced by such conditions as 
pendulous abdomen, j)revious cervical and perineal laceration, perineal 
relaxation, tumors, character and force of uterine contractions (at times 
unfavorably infiuenced by pituitarj'' preparations) and a number of other 
conditions. The head when once impacted makes spontaneous delivery 
difficult or impossible. A case which apparently offers a favorable prog- 
nosis may unexpectedly be converted into a difficult case when the head 
becomes impacted. 

An impacted head is apt to produce necrosis at the site of greatest im- 
paction. It seems plausible that if the greatest force is applied to the 
uterus between the child’s head and the promontory of the sacrum, then 
if the force and pressure is exerted beyond a certain point, the uterine 
wall becomes damaged, necrosis gradually takes place and ultimately per- 
foration may take place. It may be possible to have such perforations 
take place with ultimate healing and with no untoward results. However, 
if perchance at the time of such impaction a loop of intestine has become 
interposed between the promontory of the sacrum and the uterus, it is 
evident that a necrosis of the wall of the bowel as well as of the uterus may 
take place. The intestinal trauma may be sufficient and may be pro- 
longed enough to permit agglutination of bowel to uterus (the irritated 
peritoneum readily produces a plastic exudate) , so that by the time when 
necrosis and perforation take place, the lumen of the bov?el and the 
cavity of the uterus may be thus permanently connected even wuthout 
an extensive peritoneal infection tailing place. This is what had hap- 
pened in one of our cases, the report of which accompanies this paper. 
In another instance the force of the impaction may be exerted against the 
ventral side of the sjunphysis pubis, and this is prone to happen when 
the uterus has descended abnormally or when the cervix is abnormally 
long. The condition is usually complicated by a prolapse and edema of 
the anterior lip of the cervix. The edema makes it difficult to replace the 



248 AMERICAN JOURNAIi OP OBSTETRICS ANO Gl'NECOLOGr 

cervix to its proper position in the pelvis. At the time of the descent of 
the head, the prolapse also causes a descent of the bladder which becomes 
interposed between the uterus and the symphysis. 'When the pressure is 
exerted to the extent of producing necrosis of the uterine wall, the blad- 
der is very apt to become involved and when perforation takes place a 
vesicouterine fistula results. An instance of this sort is reported in our 
second case. 

While instrumentation is frequently resorted to on account of the im- 
paction and therefore difficult laboi*, the instrument may not necessarily 
be the cause of the trauma and fistula. It is rather the prolonged force 
and pressure exerted locally by the descending head against the sym- 
physis or promontor}’’ that is the cause of these fistulas, which may occur 
in cases where the labor is difficult, and is occasioned by the impaction 
witli impingement of the head at the site of the promontory of the sacrum 
or the symphysis pubis. 

^\Tiile it is plausible to expect necrosis and perforation of the uterus 
to occur in the difficult cases Avith impaction of the head of the child, 
nevertheless, uterine fistula associated Avith bladder or boAvel following 
labor and not directly the result of instrumentation are very rare. 

At the St. Louis Citj^ Hospital Avhere there are some 1875 obstetric cases 
treated annually, there is no record of intestinouterine or vesicouterine 
fistula having occurred. The textbooks on obstetrics do not mention these 
tj’pes of fistula. In a search of the literature it Avas found that the occur- 
rence of these fistulas is rare and that in most of the recorded cases the 
fistulas are the result of disease and only very rarely has the fistula re- 
sulted in cases folloAving labor. 

Bearing in mind the factors inAmh^ed in the formation of spontaneous 
fistulas, it is not unlikely that many so-called cases of enuresis paraljdica 
are due to fistula formation and that spontaneous healing causes them to 
disappear. As the cause of these fistulas associated with labor becomes 
more apparent, it is likely that more cases AviU be reported and that better 
statistical information will be at hand. 

In trying to prcA^ent the complication due to these fistulas, it is impor- 
tant to recognize the obsei’Amtion that anj'' abnormal condition associated 
with labor is a potential factor in producing impaction of the head as it 
passes through the parturient canal. Control of the case so as to prevent 
precipitate labor, dry labor, abnormal uterine contractions, prolonged 
labor, abnormal position of child, etc., will also help to preA’^ent complica- 
tions Avhieh result in fistula formation. 

The necessity for the correction of lacerations folloAving labor is ap- 
parent as a prophylactic measure. Proper care should be exercised in the 
administration of pituitary extract. When labor is prolonged and the 
head is engaged in such manner as to produce localized pressure, proper 
measures should, be instituted to hasten the deliA'cry. 



kirchner; eistuijA 


249 


The diagnosis of uterine fistula is usually not difacult. Careful inspec- 
tion is essential. In the case of intestinal fistula, the character of the fecal 
discharge, the results of proctoscopic examination, information gained by 
the use of rectal injections and x-ray examinations are important in 
establishing a diagnosis. The diagnosis of a urinary fistula is^ aided or 
established by cystoscopic examination. Colored solution instilled into 
the bladder often helps to locate the position and nature of the fistula. 
When it is possible to pass a probe or bougie the diagnosis may be abso- 
lutely established. As previously mentioned, spontaneous healing of the 
fistula may take place. However, if the fistula has persisted for some time 
the tract has become organized and thus established and nothing short of 
operative interference will accomplish a cure. 

Intestinouterine fistula is best treated by abdominal section which per- 
mits of proper inspection and affords greater room for manipulation and 
repair. Great skill in operating may be required to meet the conditions 
requiring correction. It may also be necessary to resort to the combined 
treatment in which operation through the vaginal route and laparotomy 
are required to effect a satisfactory cure. It is essential that cases of in- 
testinouterine fistulas have proper preoperative preparation so that fail- 
ure of the operation on this account may be avoided. 

The preoperative care in cases of vesicouterine fistula is also very im- 
portant. Certain fistulas have been healed by installation of silver prep- 
arations into the bladder or cauterization of the fistulous tract when this 
is possible. It is important to relieve the bladder of any tension due to 
the collection of urine, and the retention catheter placed in the bladder 
should be used. When the fistulous tract is not too large cure has been 
effected by means of electrocoagulation. Gottlieb^® cured a case by pass- 
ing an electrode through the cystoscope and into the fistulous opening as 
far as it would go. The tract was then coagulated in its entirety by 
slowly withdrawing the electrode with the current on. Fresh granula- 
tions gradually fill in the tract and a cure is established. 

In those cases in which the tract is well established the decision must be 
made as to whether the approach should be made transperitoneally or by 
the vaginal route. In most instances the repair can be made from below 
unless the fistula is located high on the bladder wall. The operator should 
have complete information as to the character, size and location of the 
fistulous tract. Cj^stoscopic examination and the passage of a bougie 
along the tract furnishes useful information and is a great aid to the 
operator. Szendy and Szendy®® have worked out an elaborate plan for 
the handling of vesicouterine and vesicovaginal fistulas. It must be evi- 
dent, however, that no two eases are alike and that the outcome depends 
upon the resourcefulness of the operator. In order to meet with success 
in the cure of the fistula it is most essential that the bladder in the region 
of the tract be freely mobilized. In order to accomplish this, tediouslnd 



250 


AlIERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGT 


painstaking dissection is requived. The opening in the bladder is best 
closed by suture, interrupted, continuous or purse-string, using fine plain 
catgut. The opening must be reinforced by one or two roAvs of inter- 
rupted or continuous suture lines using catgut which is not so readily 
absorbed. It is very important that tension on the sutures be avoided, 
and if possible the suture lines should not be placed over each other. The 
repair of the uterus and the A’agina must be accomplished according to 
the special indications. The Avriter has found installation of a nonirri- 
tating antiseptic solution into the A’agina of A*alue Avhen doing plastic 
operations about the genitalia. In order to prevent the accumulation of 
urine in the bladder and to facilitate treatment, a retention catheter is 
placed through the urethra and secured. The catheter is AA’orn until there 
is assurance that the. fistula has been cured. 

COIIJIENT 

Intestinouterine and vesicouterine fistulas as complications of labor 
are rare and they may be spontaneous in origin. 

Factors that are responsible for the production of variations from the 
normal mechanism of labor are prone to precipitate complications that 
may result in the production of uterine fistulas. 

In prolonged labor if impaction of the head takes place, uterine fistulas 
may develop. 

Spontaneous cures of A'esicouterine fistulas have been reported. 

Electrocoagulation in the treatment of uterine fistulas is Avorthy of 
trial. 

In the surgical treatment of A'esicouterine fistulas it is essential that the 
bladder be freelj'" mobilized, that tension on sutures be aA-oided and that 
the bladder be kept empty by the use of retention catheter until healing 
of the fistula is completed. 

1515 Lafaa'ette Aa'ENUe. 


REFERENCES 


Intestinouterine FisUiia 

(1) Amann, J. A., Jr.: Verhaiidl. d. deiitsch. Gcsellscli. f. Gynai. 8: 463, 1899. 

(2) Ahiimada, J. C., and Chevalier, Ji.: Bol. Soc. dc obst. y gincc. 8: 288-293, 1929. 

(3) Baldwin, A.: Proe. Eoj-. Soc. Med. London, 1913-14, 7: Surg. See. 71. (4) 

Bernd, L. E.: J. A. M. A. 45: 465, 1905. (5) Bernd, L. E.: Proc. Philadelphia 

County Med. Soc. 26: 288, 1905-6. (6) Bidder, A.: A''erhandl. d. deutscli. Gesellsch. 

f. Chip., 1885, XIV pt. 2, 52. (7) Cnrsliam, G.: Loudon Med. Gaz. 23: 943, 1834. 

(8) Eemarquay : Gaz. Med. de Paris 22: 341, 1867. (9) Binbech, A. T.: St. Louis 

Coup. Med. 4: 122, 1880. (10) Graves, IT^. P.: Am. J. Obst., N. Y. 57: 353, 1908. 

(11) Eanion: Rev. med. chip. d. mal. d. femmes, Papis 7 : 455, 1885. (12) Enet,Ch.; 

Ppes med. beige, Bpux. 64: 126, 1912. (13) Le Jemtel: Bull, et mem. Soc. de chir. 

de Papis, n.s. 34: 845, 1908. (14) Boenne, F.: Miinchen med. Wchnsclip. 65: 113o, 

1918. (15) Moir, C.: Internat. J. Supg. 31: 263, 1918. (16) Kexvgebaucr, F. L.: 

Rev. de gynec. et de chip, abd., Papis 2: 581, 1898. (17) NoecTcer, G. B.: Penn. M. J. 
32: 496, 1929. (18) Peraire: Papis, Chipurg. 3: 823, 1911; idem., Gynecologie, 

Papis, 1912. (19) Petit, L. E.: Ann. de gynec., Paris 18: 401, 1882; 19: 14, 1883. 

(20) Schench, TV. L.; Tr. M. Soc. Kansas, Lawrence 13: 102, 1879. 



KIRCHNER: PISTUI/A 


251 


Vesicouterine Fistula 

(21) Brodhead, G. L.: M. Eec. 98: 437, 1920. (22) Clemente, D.: Policlinco 

(sez prat.) 38: 113-116, 1931. (23) Coimwai;, TT^ P.: J. Med. Soe. New Jersey 13: 
401 1916. (24) Domhier, M.: Paris CMr. 40: 80, 1922, (25) Gainne: Pans Clur. 
13 •* 272, 1921. (26) Gottlieb, J.: Zentralbl. f. Gynak. 54: 1090-1092, 1930. (27) 

Hess, H.: Atlantic M. J. 39: 7S0-782, 1926. (28) Jonquan; Paris Chir. 1909. (29) 

Lavenant and Nagel: Paris Chir. 75: 1133-1290, 1916. (30) LuU, F. It: J. M. 

Assn, of S. Africa, May 24, 1930. (31) Noecker, C. B.: Penn. M. J. 32: 496, 1929. 

(32) Rolando, S.: Polia Gynaec. 23: 443-448, 1926. (33) Rubins, A.: Brit. M. J. 

1- 97, 1926. (34) Schmits, E. F.: Gyn. and Obst., Surgical Clinics of N. Ainer. 5; 
1^5, 1925. (35) Sims,G.K.: J. A. M. A.90: 759, 1928. (36) Ssendy, A., and E. : 
Zentralbl. f. Gynak. 53: 540-543, 1929. (37) von Thompson, H.: Zentralbl. f. Gynak. 
48; 2566-2568, 1924. (38) Verstraetcn, C.: Observation de Fistula Vesicouterine 

Guerie Spontanenient, Am. Soc. de Med. de Gaild. 54: 106, 1876. (39) Zweifel, P.: 

Monatscbr. f . Gebnrtsh. u. Gynak. 53 ; 3, 1920. 


ABSTBACT OP DISCUSSION 

DB. H. M. N. WYNNE, Minneapolis, Minn. — In reviewing the literature on this 
subject I have been impressed with the number of deliveries by high forceps operations 
which have been followed by uterovesical fistulas. Fistulas developing immediately 
after delivery are due to tears while those developing after a period of several days 
are due to pressure necrosis. 

In the examination of patients suffering from urinary fistulae the knee chest posi- 
tion is of great value. 

Surgical repair by the vaginal route may be facilitated and made easier by the 
use of the Schuohardt incision. However, I believe that a more satisfactory closure 
can be made in the majority of cases by thorough mobilization of the bladder wall at 
the site of the fistula. The cure of fistulas by electrocoagulation is necessarily limited 
to small openings. The suprapubic operation is necessary in certain eases for ade- 
quate exposure and mobilization of the bladder. 

We know that a considerable number of these fistulas have healed spontaneously. 
Unless a very large fistula is present, it would seem advisable to place a retention 
catheter in the bladder at once and give nature a chance. 

In the preparation for operative closure of a sigmoidouteriue fistula it may be ad- 
visable to divert the fecal current by colostomy as a preliminarj' measure. A large 
rubber tube passed through the anus above the site of the closed fistula in the bowel 
and allowed to remain for several days will be found of value in some cases. 

DR. KIRCHNER (closing). — There are a number of these cases reported of fistula 
resulting from disease or from trauma. My object in presenting this paper in this way 
was to encourage surgeons to report their eases and to relieve us from the possibility 
of damage suits by giving this information. I do not believe that every case of fistula 
is necessarily the fault of the obstetrician. In these two cases reported the families 
of the patients were making preparation for damage suits. This paper was written 
more with the object of calling attention to the spontaneous cases than anything else. 

In regard to the treatment, it should be borne in mind that the principle of mobili- 
zation of the bladder is very important. I have had occasion to reoperate on cases 
of vesicovaginal fistula and in those cases where mobilization of the bladder was 

properly done cures were obtained. Where the bladder was not mobilized, failures 
resulted. 



MULTIPLE DERMOIDS OE THE OVABY^ 

Jajies Raglan SIiller, IM.D., Hartford, Conn. 

TT IS the purpose of this paper to review the experience Avith dermoid 
cysts of the ovary at the Hartford Hospital from 1916 to 1932, to em- 
phasize the necessity of conservative surgery in view of the frequency of 
bilateral involvement, and to re%uew briefly the literature. 

Lebcrt* and Panly* were able to collect 108 instances o£ bilateral dermoid cysts 
up to 1870. a. Loewy and P. GuenioP collected 88 additional cases up to 1902. The 
latter authors gave the frequency as 20 in 117 where the second ovary was similarly 
involved, and they, as welt as subsequent writers, reported no particular effect on 
menstruation or on pregnancy. They advised conservation of tissue by resection of 
the tumor only where possible. They thought the diagnosis of dermoid cysts was 
seldom made, and of bilateral dermoids almost never made before operation. They 
urged careful examination of the second ovary at operation. 

Table I shows some of the larger series in which the frequency of bilateral dermoids 
is reported: 

Table I 



DERMOIDS 

BILATER.\L 

PER CENT 

B. Loen 7 and P. GuenioP 

W. Eosenstein,* from literature 

117 

20 

10-40 

G. Van S. Smith* 

97 

5 


S. A. Chalfonp 

16 

2 


J. M. Marshall* 

415 

63 

15.4 

Gardiner* 

24 

2 


Fleming* 

20 

1 


Lochrane and Keating* 
Mandelstamm* 

22 

6 

14 

Steuber and Brandcss* 



18.5 

Kusudo Shogi® 



15.9 

August Mayer* 

Lippert** 



18.4 

10.61 

Glockner“ 



11 

Bavano** 



13.6 

Gebhardt** 



17.58 

Ikeda’“ 



25.4 

Satow” 



31.17 

Mantel'* 



40 

Present series 

90 

oo 

25 


W. Blair BeU“ says, ‘ ‘ Pew surgeons give any consideration to the surgical treatment 

of innocent neoplasms other than the complete removal of the organ As a 

rule some healthy portion of ovary can be preserved with its normal connections for 
nearly every neoplasm tends to grow away from the hilum, and the preservation of 
this, with adjacent ovarian tissue leaves well nourished and functional tissue. ' ’ 
Prank S. Matthews^ emphasizes the wisdom of conserving ovarian tissue in the 
presence of pregnancy. The line of cleavage between cyst and ovarian tissue is easily 
followed. He reports six cases of bilateral dermoids of which four were associated 
with pregnancy. Enucleation of the dermoids was practiced in all but one case. Preg- 

*Read at the Forty-Fifth Annual Meeting of the American Association of Obstetri- 
cians, Gynecologists and Abdominal Surgeons, French Lick Springs, Ind., Septemoer iz, 

13, and 14, 1932. 


252 




MILLER ; MULTIPLE DERMOIDS OP OVARY 


253 


nancy continued in two where corpora lutca were removed at the second and fifth 
months of gestation. 

Eisenstadter“ found three cancers in 13 dermoids; Lippcrt'° believed cancers oc- 
curred in 3 per cent of dermoids ; Hoehner” found three cancers in 7 dermoids ; Wilms” 
states the belief that malignant growths are found more frequently in bilateral than 
in single dermoids. 

Masson and Ochsenhirt” reviewed 33 cases of squamous cell cancer originating in 
dermoids and added 3 new cases. They put the frequency of such changes at from 
0.5 to 5 per cent of all dermoids, urging careful microscopic examination of all dermoid 
cysts. Eohdenburg” found 6 malignancies among 61 dermoids. 

Marshall," in a brief report, presented what is perhaps the largest number of 
dermoid cysts ever reported from a single clinic (Mayo up to 1928). The outstanding 
features of this report are as follows: 

There were 415 dermoid cysts representing 4 to 5 per cent of all ovarian tumors 
removed. There were 60 per cent between thirty and fifty years of age, the greatest 
age incidence being thii’ty-eight years. Twelve per cent had twisted pedicles, 15 per 
cent involved both ovaries, 4 per cent were infected, 1 per cent gangrenous, 1.9 per 
cent malignant. The dermoid cyst was an incidental finding in 32 per cent. There 
were 225 out of 285 married patients who had had one or more pregnancies. In none 
was a definite preoperative diagnosis made. 

G-. Van S. Smith* reported no malignant degeneration found in 97 dermoids. In 
29 per cent the finding W'as incidental. He advises conservation of ovarian tissue if 
possible. 

V on Vranque” gives the incidence of dermoids as about 10 per cent of all ovarian 
tumors and states that they are often bilateral, cancer developing in 3 per cent of 
dermoids. 

Joseph Novah” reported a patient who showed 10 dermoids in one ovary and 11 in 
the other. 

August Mayer" puts carcinomatous degeneration of dermoids at 4)4 per cent. He 
questions W. A. Freund’s statement that hypoplasia of the genital apparatus is a 
fairly frequent accompanying sign of dermoid tumors of the ovary. Mayer was able 
to find this in only 4 per cent. Freund also spoke of the predilection of dermoid cysts 
for the anterior culdesac, 

Lochrane and Keating" reported cancer in 2 out of 6 bilateral dermoids. 

During the past sixteen years at the Hartford Hospital, up to August 1, 
1932, we have observed 90 patients with dermoid cysts of the ovary, this 
inimber including patients of all physicians. Of these I have operated 
personally upon 22 ; this is a largei* number than I should have expected 
as mj" share. ^Yhen I noted therefore one of the histories in which one 
dermoid was removed followed by the removal of the other one year later, 
without a note of the condition of the remaining ovary at the first opera- 
tion, I wondered if some instances ivere not overlooked. Of the 12 cases 
where dermoids complicated pregnancy, I found that 9 were my own, and 
that I had assisted with two others. 

In a large general hospital whei'e cross indexing of diagnoses is less 
perfectly done in fJie earlier years than in some of our teaching hospitals. 
It frequently happens that this diagnosis is not recorded, for it may he 
an incidental and unimportant fourth or fifth complication in the case. 
Some surgeons are satisfied with gross inspection of the tumor, thereby 



254 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


saving' the patient a laboratory fee, and in this regard the present series 
is not thoroughly checked. 

In addition to consulting the hospital cross index of diagnoses, I have 
collected from the operating room records and from the laboratory a large 
number of added cases. Such an experience probably can be duplicated 
in most general hospitals. I believe, however, that the list is fairly 
complete. 

Of the 90 patients having dermoid cj'sls, 12 were complicated by preg- 
nancy, one bilateral dermoid died of peritonitis, follo'ft'ing accidental in- 
jury of the small bowel ; 12 had twisted pedicles ; 22 involved both ovaries. 
In all, 6 cases had more than two dermoids, the largest number being 4 on 
one side and 2 on the other. Three incomplete operations were known to 
have been done, one of these having been referred to. The second patient 
was pregnant in the second month, and the dermoid in the ovaiy which 
contained the corpus luteum was not removed for fear of disturbing preg- 
nancy. This patient however, aborted two weeks later. The third patient 
was my own in whom a small dei-moid, 2 cm. in diameter, was found inci- 
dental to a complete removal of the pelvic organs. I had operated on this 
patient eight years previously, and a detailed note described the other 
ovary as entirelj^ normal in appearance. 

Of the 12 eases complicated by pregnancy, 6 patients were delivered 
at term by cesarean seetion, 4 because of blockage in the peMs. In one 
of these I made a positive diagnosis substantiated by x-ray at the third 
month, and the cesarean section was done at the patient’s request, she 
being thirty -nine years old in her first pregnanejL In one case the der- 
moid was adherent in the culdesac and was removed at a. subsequent opera- 
tion. In the other two the cesarean section was done for other reasons 
and the dermoid cyst was an incidental finding. In the 6 cases where preg- 
nancy had advanced to the sixth to twelfth week, one came to the hospital 
infected with a criminal abortion. The broad ligament abscess which re- 
sulted was drained above Pouiiart’s ligament, and I unfortunately punc- 
tured the dermoid cavity as well. After many weeks the adnexa on this 
side were resected sueeessfully and the patient later became pregnant. In 
one case previously mentioned abortion occurred following operation, 
in another the outcome was not Icnown, and in 3 I was able to deliver a 
live baby. 

One of these cases is worthy of more detailed mention: A Danish 
woman, aged twenty, six weeks pregnant, had an acute attack of right- 
sided pain. Diagnosis of early pregnancy and twisted ovarian cyst was 
made and operation promptly performed. The right ovary was a t'wisted, 
fist-sized dermoid and had to be removed entire. The uterus was ante- 
flexed and six weeks pregnant, the corpus luteum in the left ovaiy lying 
between two dermoid cysts 2 by 3 by 4 cm. and 3 by 4 by 5 cm. respectively. 
At first glance, complete removal of the left ovary seemed necessary but 



MILLER; MULTIPLE DERMOIDS OP OVARY 


255 


the cysts were carefully enucleated, suturing the cut edges of ovarian tis- 
sue adjacent to the corpus luteum with plaiir catgut on an intestinal 
needle. This patient went to teim and has menstruated regularly for 
more than a year. 

A twenty -year-old pupil nurse having a basal metabolism 20 to 30 be- 
low normal Avas operated upon because of bilateral abdominal tumors ; one 
ovary containing four dermoids was removed entire; in the other the 
corpus luteum was located between two dermoid cysts which were 
enucleated as in the previous case. This patient has menstruated reg- 
ularly for several months. 

The preoperatiA’^e diagnosis of dermoid e 3 ’'sts has been made on several 
occasions and of a tivisted dermoid once, confirmed bj'’ operation. 

In a recent case I made a preopei'ative diagnosis of bilateral dermoids 
of the ovarj’^ which proved to be correct. I Avas unable to resort to x-ray 
examination in this ease, but was led to the diagnosis by the following 
considerations : One of the cysts la}'’ in the anterior euldesac. This pa- 
tient, aged tAventj'-four, had alwaj's menstruated irregularly, infre- 
quentlj’’, and scantily, and the presence of a high-grade funnel peh'is sug- 
gested the possibility of abnormal developmental growths although there 
is probably scant basis for this conjecture. This patient Avas treated in a 
similar conservative Avay and is uoav menstruating regularly for the first 
time in her life. This case appears to refute the older teaching that der- 
moids have no influence on menstruation. 

Of the 22 patients who had bilateral involvement, three had more than 
one dermoid in the other ovary, and two Avere complicated by pregnancy. 
The age distribution shoAvs that 12 of the 22 Avere under thirty-one years 
and 17 Avere under forty-one years of age. This frequency of bilateral 
invoh'ement during the childbearing period emphasizes the necessity for 
considering conservation of ovarian tissue. 

In this series no case of malignancj’’ arising in the dermoid cj^st was 
noted. About 80 per cent of the dermoids were examined by the 
pathologist. 

SUMMARY AND CONCLUSION 

1. Dermoid cysts Avere found in both ovaries in 25 per cent of 90 eases 
and more than one dermoid in a single ovary Avere found in 7 per cent. 
This frequency demands careful inspection of both oA'aries before decid- 
ing Avhat to do. 

2. Conservation of ovarian tissue by enucleating the dermoid cyst is 
an easy and valuable procedure Avheu operating on a Avoman in the child- 
bearing period; this may be carried out during pregnancj' Avith little 
added risk. 

3. The practice of relying on a gross examination is mentioned merely 
to condemn it, for maliguaney arising in a dermoid occurs frequently 
enougli to Avarrant careful microscopic examination in every case. 



256 


a:merican journal op obstetrics and gynecology 


REFERENCES 

(1) Lchcrt and Pauly: Quoted by Loewy and Gueniot. (2) Loewy, J?., and 
Gucniot, P. ; Ecv. de Gjticc. et dc cliir. abdoin. G: 246, 1902. (3) Eosenstein, TV.; 
Monatschr. f, Geburtsli. u. Gyniik. 78: 302, 18: 666, 1928. (4) S 7 niih, G. Van S.: 

Am. J. Obst. & Gynec. 18: 666, 1929. (5) Chalfani, S. A.: Penn. M. J. 34: 537, 
1931. (6) Marshall, J. M.; Reports of Staff Meetings of the Mayo Clinic 3: 4, 1928. 
(7) Gardner; J. Obst. Sc Gynec. Brit. Emp. 38: 333, 1931. (7) Fleming; J. Obst. 

& Gynec. Brit. Emp. 38: 280, 1931. (7) Lochranc and Keating: J. Obst. & Gynec. 
Brit. Emp. Summer 1931. (8) Mandelsiamm, Stuehcr and Brandcss, K^isudo Shogi: 

Quoted by Fleming. (9) Mayer, Augu.<it: Halban & Seitz Biol. u. Path, dcs Weibes' 5: 
859. (10) Lippert, Glochner, liavano, Gchhardt, Iheda, Satoio, Mantel; Quoted by 

Mayer. (11) Bell, TV. Blair; Am. J. Cancer 16: No. 1, 1932. (12) Matthews, 

Franl; S.: Ann. Surg. 82: 483-485, 1925. (13) Eisenstadter: Monatschr. f. 

Geburtsli. u. Gyniik. 54: 360, 1921. (14) Jlochmr, TVihns: Quoted bv Eisen- 

stadter. (15) Masson and Ochsenhirt: Surg. Gynec. Obst. 48: 702-708, 1929. (16) 
Bohdenhurg: J, Lab. & Clin. Med. 12: 211, 1926. (17) von Franque: Menge & 

Opitz Handbuch der Frauenheilkunde, 1913. (IS) Koval:, Joseph; Beitr. z. Path. 
Anat. u. z. Path. 14: 1-37, 1909. 

179 Alltn Street. 


ABSTRACT OP DISCUSSION 

DE. WILLIAM H. WEIR, CLEraLAXD, Omo. — Our material has been relatively 
limited. We do not seem to see dermoids very frequently. I have never encountered 
a dermoid showing malignancy, although in one case it was suspected, but the suspi- 
cious area proved to bo well defined thyroid tissue. Generally they enlarge slowly by 
a gradual accumulation of the secretions from the skin in the interior of the cyst. It 
has been my practice, when encountering so-called polycystic ovaries, to puncture the 
numerous follicle cj'sts when the ovaries arc to be conserved. On one occasion the 
contents of one cyst showed that it was a typical but ver}- tiny dermoid. In another 
case the thick mucous fluid exuding from a cyst about 1 cm. in diameter showed that 
it was not a follicle and microscopic examuiation proved it to be a pseudomucinous 
adenocystoma. There is a decided tendency for dermoids to become necrotic and 
one must be very careful in palpating such cysts before packing off the abdomen, lest 
they rupture. On one occasion this happened with a huge dermoid reaching above the 
navel. Suddenly it ruptured wide open, flooding the whole abdomen ■o'ith a mixture of 
hair, sweat, and sebaceous material, and I had difficulty cleaning up with gallons of 
fluid. The patient fortunately recovered but after a very stormy convalescence. 
Dermoids should be removed without preliminary tapping as the hair and sebaceous 
material -n-ill usually clog the cannula. 

DR. JAMES E. DAVIS, Ann Arbor, Mich. — There is a characteristic familial 
feature in a certain percentage of these cases. In certain cases all of the women 
will have dermoids. 

Another point in the diagnosis of dermoids is that very often the macroscopic is bet- 
ter than the microscopic examination because, the tissues niaj’ show a total destruction 
of the epidermoid units but macroscopically the units can be easily recognized. 

DR. EDWARD J. ILL, Newark, N. J.— The inclusion theory of Cohnheim as a 
cause for the existence of dermoids has never appealed to me. Many years ago I came 
across Eegier’s suggestion that the tumor he described, containing almost an entire 
skeleton, was of parthenogenetic origin. This appealed to me. Later Pfannenstiel, 
found that segmentation of the unfertilized ovum took place. Soon after that an 
American article appeared in which it was claimed that sixteen thousand serial sec- 
tions of the ovary of the unfertilized guinea pig would show that such segmentation 
really takes place. It immediately occurred to me that here was an explanation of 
the reason for the production of dermoids of the ovary. It also would explain why 
we may find two or three dermoids in an ovary at the same time. 



PROLAPSE OP THE UTERUS’^ 

"W. A. Coventry, M.D., and Russell J. Moe, M.D., Duluth, Minn. 

(From the Buluth Clinic) 

P rolapse of the uterus has ahvaj^s presented to the gynecologist an 
interesting problem because of the many factors involved in its causa- 
tion and also in the methods to be pursued* to correct the deformity that 
has taken place. In our series we have been particularly pleased because 
of the large percentage of eases in ■which we have been able to give com- 
plete relief to the patient. 

In our series a larger percentage were due to the use of forceps in the 
hands of the average practitioner ; a smaller percentage of patients with 
prolapse were confined in the home or had been confined by midwives, 
but practically all cases had had lacerations which had not been repaired. 
We have encountered onlj’’ one case in a virgin, and in this case we at- 
tibuted the prolapse entirely to atrophic conditions of the muscles of the 
pelvic flooi*. We have found too that the incidence of prolapse is much 
greater in that type of patient who has had to work hard in the home or 
on the farm, where the increased intraabdominal pressure accompanying 
this type of work is a factor in the causation of prolapse. 

In determining the type of operation to be performed, the degree of 
prolapse is of considerable importance. The age of the patient is impor- 
tant also. Is the patient young 1 Is she in the childbearing age ? Is she 
near or past the menopause ? Is there a ej’-stocele, rectocele, or both ? Is 
the uterus small, atrophic, or is it of normal size ? Is there marked pro- 
longation of the cervix; is there ulceration of the cervix? Are there 
fibroids or are there adhesions binding the uterus? Is there a true hernia 
of the vault of the vagina? Have the muscles lost their tone? 

The more experience one gains from treating cases of prolapse, the 
more one is impressed with the fact that the evaluation of these many 
factors is of extreme importance. We have seen a diagnosis of prolapse 
of the uterus made when it really was a true hernia of the vault of the 
vagina. We have seen it made when there was a large rectocele and the 
uterus decidedly fixed and in good position. We have seen it where there 
was a large cystocele bulging into the vulva. These errors, of course, are 
only made by those who are careless and avIio do not take the time to evalu- 
ate the exact picture that presents itself to the one making the diagnosis. 

On the careful evaluation of these many diagnostic points depends 
exactly the tj’pe of operation that should be performed. In this paper, 
however, we shall consider only that type of case in which there is a second 

and third degree prolapse of the uterus with or without cj^stocele or 
rectocele. 




257 



258 AJIERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 

The literature is abundant ivitli types of operations to be performed. 
In our opinion, any type of abdominal fixation of the uterus for prolapse 
should not be performed. In vaginal operations the morbidity and mor- 
talitj^ are veiy markedly decreased over the abdominal route. We have 
seen many bad results from supravaginal hysterectomy, fixation of the 
uterus to the anterior abdominal Avail, splitting the uterus and burying 
it in the abdominal Avail, until uoav avc are firm coiwerts to the interposi- 
tion operation as being the operation of choice for prolapse of the uterus. 
W e are fully aware of the fact that in England the Manchester tj^pe is 
generally performed. 

There are tAvo types of interposition operation Avhich Ave prefer; the 
Wertheim-Watkins and the Mayo A'aginal hysterectomy modification. In 
the Wertheim-Watkins operation the uterus should be large enough to be 
interposed hetAveen the vaginal Avail and the bladder so as to make a true 
Avedge and firm fitting structure to secure the cystocele. If, however, the 
uterus is small aud atrophic, I believe the vaginal liystereetomy per- 
formed after the method devised by the Mayos in Avhich the broad liga- 
ments are brought together and interposed betAveen the anterior vaginal 
Avail and the bladder gives the most satisfactory results. An important 
feature of the Wertheim-Watkins operation is the fixation of the cervix 
high in the vaginal vault. In the event amputation of the ccrA’ix is neces- 
sary the stump should he treated in tlie .same manner. It seems needless 
to say that a perineorrhaphy is ahvays necessary. The degree of the 
perineorrhaphy Avould depend largely upon the age of the patient, marital 
state, and the degree of laceration. 

In the Mayo type of operation it is some times necessary to insert a 
purse-string suture, incorporating the uterosacral ligament. 

Many cases of prolapse haAm an ulceration of the ceiwix, but in our 
experience Ave have never seen a carcinoma of the ceiwix in a second or 
third degree prolapse. It does not necessarily folloAv, hoAveA'^er, that this 
cannot happen, but this has been our observation. 

When should one do a Mayo type of operation? If the uterus is small, 
as it often is in senile Avomen ; if it is a bleeding uterus of fibrosis uteri ; 
if the uterus contains multiple fibroids of not too large a size, then a 
Mayo type should be performed. If tlie uterus is of sufficient size to be 
interposed, the Wertheira operation should be done. We liaA^e in several 
cases AAffiere fibroids Avere small performed a myomectomj^ and then inter- 
posed the remaining uterus. It is our opinion that in all Wertheim- 
Watkins operations the patient should be sterilized without exception. 

We Avish to report a series of 110 cases, ranging in age from tAventy- 
seAmn to sixt 3 ’’-nine j’^ears. The majority Avere at or near the menopause, 
the average age being forty-nine years. We liaAm been able to follow up 
either personally or bj'^ letter 100 cases, from Avhich the following con- 
clusions can be drawn. 



COVENTRy AND IMOB : PRODAPSE OP UTERUS 


259 


Fifty-three per cent were known to have had instrumental deliveries. 
The number of labors varied from one to thirteen, the average being 4.8 
labors. In our series of 110 eases we had one postoperative death a pa- 
tient fifty-two years of age, operated in 1921, developed a hyperthyroid 
crisis which Avas unrecognized at the time of operation. This patient died 
on the second day postoperatively. Two additional patients have died 
since operation, one from carcinoma of the stomach and in the other case 
the cause of death was undetermined. From information available it had 
no connection Avith the pelvic condition. 

In this series of 100 cases Avith complete “folloAv-up” 70 Avere of the 
typical Wertheim-Watkins interposition operation, the remaining thirty 
having the Mayo type AA'ith A^aginal hj'^stereetomy. In those of the typical 
AVer theim- Watkins interposition type successful anatomical results AA^ere 
obtained in 69 of the 70 eases, one ease being a failure on account of re- 
currence of prolapse of the fundus through the anterior AA^all of the An- 
gina. Either the uterus Avas too small for an iiiterposition type of opera- 


Table I. Summary 



WATKINS- 

AVERTHEIM 

MAYO 

TOTAL 

Number of caises 

76 

% 

34 

% 

110 

1 % 

1 

Number of follow-up 

t 70 

1 


30 


1 100 


Successful anatomically 

69 

98.6 

i 

25 1 

1 

83.3 

94 

94 

Failures anatomically 

1 

1.4 

5 

16.7 

6 

6 

Successful symptomatically 

66 

94.3 

26 

86.6 

92 

1 

92 

Failures symptomatically 

4 

•5.7 

4 

13.4 ' 

1 

1 

8 ' 

I 

8 


tion or the anchoring sutures gave aAvay. Tliis taught us that a close 
anchoi-ing of the fundus of the uteims under the pubes by four absorbable 
sutures is very essential. The two medial sutures should be parallel to 
and quite close to the urethra. 

Four of the 70 cases had sjunptomatic failures, complaining as folloAA'S: 

One had some discomfort during menses. 

One had urinary incontinence of a mild degree. 

T(vo liad frequency and occasional dysuria. 

These are classified as symptomatically uiisnccessfnl results because the 
patient Avas not fully satisfied. There is some doubt whether or not the 
complaint is a direct result of the operative procedure. All of these four 
eases, hoAvever, had very good anatomical results. 

The Mayo type of A-aginal hysterectomy Avith interposition of the broad 
ligaments was performed in 30 cases and the end-results show a successful 









260 


AjMERICAN journal op obstetrics and gynecology 


anatomical outcome in 25 cases. The anatomical failures in this type of 
operation, five in number, had prolapse of tlie vault of the vagina and 
varying degrees of discomfort. 

CONCLUSIONS 

From these observations ve can draw the following eonelu.sions : 

The 'Wertheim-'Watkins operation is the operation of choice where the 
size of the uterus permits its interposition. 

The Mayo hysterectomy, interposition type, is indicated where the 
uterus is small and will not iiermit its interposition. 

Failures in the Wertheim-Watkins operation are negligible, in our 
series, one in seventy. 

Failures in the Mayo type of operation were 5 in the 30 cases operated. 
All 5 cases had a prolapse of the vault of the vagina. Failure ma 3 ' be pre- 
vented bj' better closure of the space between the broad ligaments and 
the uterosaeral ligaments. 


REFERENCES 

(1) JKaer, J. L., (ind Jlcis, J?. A.: Aji. J. Oust. & Gykec. 17: 233, 1929. (2) 

Bloovi, 0. Jl.: N. y. State Med. J. 30: 19, 1930. (3) Brachj, Leo: Surg. Gynec. 

Obst. 43: 476, 1926. (4) Bullard, E. A.: Alt. J. Obst. & Gynec. 11: 623, 1926. 

(5) Claris, J. G.: Surg. Gynec. Obst. 1925. (6) Counscllcr, V. S., and Staen, LedaJ.: 
J. A. M. A. 95: 983, 1930. (7) Cron, It. S.: Surg. Gyiicc. Obst. 43: 698, 1926. (8) 
Croivson, H. S.: J. Missouri S. Med. Soc., February, 1931. (9) Johnson, F. W.: 
Surg. Gynec, Obst. 42: 527, 1926. (10) Masson, J. C.: Minnesota Med. 12: 67, 
1929. (11) Mayo, TV. J.; J. Obst. & Gyn. June, 1927. (12) Meshhurg, P. : An. J. 

Obst. & Gynec. 21: 398, 1931. (13) Phaneuf, L. E.; New England J. Med. 201: 
875, 1929. (14) Watlsins, T. J.: Tr.ans. Am. Gjm. Soc. 34: 123, 1909. 

205 West Second Street. 

ABSTEACT OP DISCUSSION 

DE. H. W. KOSTMAY^EE, New Okee.yns, La. — ^IV e have a different criterion for 
determining wlietlier we sliould do an interposition operation or a vaginal liyster- 
ectomj-. We do not consider the size of a uterus so much as the degree of descent. 
To put it another waj', if the outstanding pathologic change is that of relaxation of 
the anterior vaginal wall with a moderate degree of prolapse of the uterus, so-called 
second degree, we feel that if there is no contraindication such as disease of the uterus 
or fibroids, that the interposition operation is the method of choice. If there is com- 
plete descent of the uterus associated uith cystocele or without it, the operation of 
choice is removal of the uterus. We base the assumiition on the fact that after all 
when you are operating for prolapse of the uterus or for large cystocele you are 
operating because in the final analysis the broad ligaments have so elongated that 
they permit of descent of the uterus in the one instance, or in the case of a large 
cystocele you are depending on the broad ligaments ultimately to support the structure 
that has been damaged, that is the anterior vaginal wall. So we carry this a little 
further and determine the amount of broad ligament that should be removed. If we 
do the Mayo tj’pe of operation and there is moderate elongation of the broad ligaments, 
we take out as little as possible in removing the uterus. If there is an exaggerated 
tj^e of prolapse we go well out on the broad ligament structure, even at times re- 
moving tubes and ovaries with it. And so we base our theory of this procedure on 
the fact that we are going to support the structure with the broad ligaments that 
have elongated so that they’ can no longer hold the structures within the pelvic cavity . 



COVENTRY AND AIDE: PROLAPSE OP UTERUS 


261 


DE. L. A. CALKINS, Kansas City, Mo. — selecting the type of operation for 
prolapsed uterus, 1 think we should perhaps pay a little more attention to etiology 
than has keen brought out so far in this discussion. It is true that almost all cases 
of prolapse of the uterus do give a history of a prolonged, instrumental, or otherwise 
difficult labor. However, it is also true that the majority of cases of prolapse of the 
uterus occur in individuals who are asthenic. Ample proof of that is had from the 
cases of prolapsus in nulliparae. We recently had a case of prolapse in a newly born 
baby. Occult (or frank) spina bifida is known to be definitely associated with these 
cases and it is undoubtedly true that faulty nerve development is a great factor in 
the production of prolapse. 

We therefore do not depend upon the relaxed broad ligaments in any ease of definite 
prolapse. We do depend upon and routinely repair the pelvic floor to hold the cervix 
up behind, and perform a suspension operation to hold the uterus up in front. If the 
uterus be too small to be swung across the pelvis from anteriorly, at the symphysis, 
to the levator ani sling, posteriorly, we do an interposition operation because the 
uterus is still long enough to reach from the arcuate ligament to the strong part of 
the pelvic floor. We do not do a vaginal hysterectomy. 

DE. F. H. FALLS, Chicago, III.— I would like to add two points to the discussion. 
First, as to the use of local anesthesia in these cases. A good many of these prolapses 
occur at a mature age and we have found that local anesthesia reinforced by morphine 
and scopolamine lends itself very w'ell to the performance of this operation. 

Another point is to cite a case in which a prolapse occurred in a rather elderly hard 
working woman. I did an interposition operation under local anesthesia followed by 
a perineorrhaphy. Because of her asthma and the increase of abdominal pressure, 
and also because of her occupation, the uterus was again completely prolapsed within 
a year after the interposition operation. I waited until June when her asthma was 
at its best and opened the anterior vaginal wall, freed, and pushed the uterus back 
into the abdomen. I then opened the abdomen and did a ventral fixation. Following 
this I overlapped the fascia of the anterior vaginal wall and did a perineorrhaphy. 
The woman had a rather stormy time for a few days but recovered and was able to 
do lier hard work afterward and, in spite of asthmatic attacks, did not have a 
recurrence. 

One other point which I think should be made is that in all of these cases of pro- 
lapse where a plastic operation is done we routinely do dilatation and curettage and 
also biopsy of the cervix to bo sure that there is no beginning cancer before we do 
tho plastic operation. 


DE. COVENTEY (closing). — ■! think Dr. Kostmayer misunderstood me. We have 
never had a cystoccle occur after these operations, but we have had a prolapse of the 
v.ault of the vagina, after a klayo operation, which is a difficult thing to repair. If 
it is repaired, it means that the vagina has to be practically closed. It is this which 
wo liave tried to prevent by incorporating a stitch, which I think was described by 
Frank, so as to close off the vault of the vagina. 

As far as the etiology is concerned, most of our cases were not of the asthenic type. 
There are cases of the congenital type, but we had only one in a virgin, and that was 
m .an asthenic type of individual. In one case of prolapse operated by Wertheim 
method I used a linen suture to hold the fundus well up under the pubes. I afteiAvard 
did this on other eases but in this locality the linen stitch is not absorbed, so we went 
back to the absorb.able suture and placed it so as to hook the uterus more closely 
.around the urethr.a. The lifting of the stump of the cervix, or the eervLx itself, very 
high m the ^agnlal vault, ivhich is the Manchester method used in the British Empire 



A REPORT OP THE END-RESULTS OP 554 CONSECUTIVE 

HYSTERECTOMIES* 


Louis E. Phaxeuf, M.D., P.A.C.S., and Maurice 0. Belsox, M.D., 

Boston, Mass. 

(From Vic Gynccologicul and Ohstctrical Service of the Carney Jhospital) 


' I 'HE interest sllo^Yn in the discussion of hysterectomy at the Septem- 
her, 1931 meeting.of this Association, lield at "White Sulphur Springs, 
has led ns to survey the operations performed on the Gynecological and 
Obstetrical Service of the Carney Hospital from January, 1915 to August, 
1931, a period of fifteen years and seven months. 

The iioints of interest in connection vith hysterectomy are three in 
number, namely, (1) total ver.sns subtotal hysterectomy; (2) the technic 
of operation; and (3) the end-re.sults. 

On the question of total versus subtotal hysterectomy the opinions are 
far from uniform. We have taken a middle ground. The age and the 
general condition of the patient are the factors on -which tlie selection of 
the type of operation has been based. It is admitted that a badly lacer- 
ated and irritated cervix should not be left behind when hysterectomy is 
performed. "Y^ith -n’omeu at the age of tlie menopause we have preferred 
removing the entire uterus. "When similar lesions are present in the 
younger women, -we have felt that the cervix should be conserved to pre- 
vent the changes occurring in the vaginal vault following total removal. 
In order not to leave behind a lacerated or irritated cervix, we have treat- 
ed it by trachelorrhaphy, by conical amputation (Sturmdorf), by total 
amputation, by cauterization, and of late, by conization with the high 
frequenej^ current, using the Hyams technic and the electrode he has 
devised. In eases where the eeiwix is healthy and retained, we remove the 
cervical mucosa by coning it from aboA'c. B}'- leaving a healthy eeiwix be- 
hind, Ave haAm OAmreome the chief objection to supraAmginal amputation 
of the uterus. GWen a Avoman in poor physical condition Avho needs a 
hysterectomy because of a benign lesion Ave prefer the subtotal procedure 
in the presence of a health,y cerAUX. If, on the other hand, the cerAUX 
needs attention, we do the operation in tAvo stages, first the cervix and tAvo 
Aveeks later the abdominal part of the operation. The technic of opera- 
tion is Avell standardized and needs no detailed elaboration at this time. 
There are four distinct steps inAmlAmd : (1) the removal of the uterus; 
(2) the tying of the vessels of each side ; (3) the suspension of the ceiwica] 
stump or the Amginal cuff as the ease may be ; and (4) the coAmring of all 
raw areas by peritoneum. Drainage is seldom necessary in the incom- 


‘Read at the Forty-Fifth Annual Meeting of the American •A-ssociation of Ob- 
stetricians, Gynecologists and Abdominal Surgeons, French LicK Springs, a 
September 12, 13, and 14, 1932. 


262 



PHANEtIF AND BEESON: tlYSTERECTOAIIES 


263 


plcte ov subtotal operation. When it is, it can readilj' be aecomplisbed 
by splitting the posterior lip of the cervix and introducing the drain in 
the vagina. Following the complete removal of the uterus, the vagina 
may be closed tightly as was done in many of our eases, or free vaginal 
drainage may be instituted. In many important European clinics they 
are leaving the vagina wide open and draining the parametria freely with 
gauze, preferably iodoform, claiming that the mortality and morbidity 
of the total hj’sterectomy is no greater than that of the subtotal ivhen this 
procedure is employed. Interested by their results we are, at the present 
time, doing a series of eases with this method of drainage. We are favor- 



Pigr. 1. — Shows tlie mortality of the three groups hy operators. It is only fair 
to state that In the last two periods most of the had risks were operated upon hv 
one of us (Phaneuf). Taking the group of 300 cases by Phaneuf, in the panhys- 
terectomies during the first five years, the mortality is given as 33 per cent. This 
group contained six cases with two deaths. One of the patients had a postopera- 
tive psychosis, jumped out of a window, and fractured her skull, whereas the other 
had acute cardiac failure after operation. The second five year group showed a 
gradual decrease in the mortality. In the last period of six years the mortality of 
panliystorectomy was 2.17 per cent. In the supravaginal hysterectomies the chart 
records a definite decrease in mortality, from 10 per cent in a small series making 
tlie first group, to 2.0 per cent in the last. Glancing at the total group by 13 oper- 
ators including Phaneuf the mortality of the first two periods is but little changed, 
wliilo it is markedly decreased in the last period. The chief factors in improving 
the mortality rate have rested in belter preoporative preparation, improvements in 
anostliesia, shorter operating time, improved technic and better postoperative care 


ably impressed witlv ouv results althougli the number of patients is as yet 
too small to permit any conclusions. 

We liave analyzed tlie end-results of 554 consecutive hysterectomies of 
all types whicli are presented in tables and charts for tlie sake of con- 
venience. Three liundred of these operations were performed by one of 
ns (Phaneuf), and 254 by 12 other operators. 

Table I shows tliat panliystercctomy Was performed in 26 per cent of 



264 


AJIERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGA' 
Table I. Distribution of Cases as Regards Parity and Menopadse 


NULLIPAR.V PRISIIPARA MULTIPARA MENOPAUSE 


Panli 3 -sterectomj' 

Supravaginal 

Vaginal 

Porro cesarean section 

Hysterosalpingcctomj- 

■Wertlieim 


Per cent 

Per cent 

33 

12 

43 

14 

3 

11 

0 

25 

12.0 

12.5 

0 

25 


Per cent 

Per cent 

55 

26 

43 

9 

86 

54 

75 

0 

75 

0 

75 

25 


rD'.'j'ii* I'criiir!.'! . i* 



Fig. 2. — Graphically shows tlie morbidity in percentages. Our standard of 
morbidity for this purpose has been 101” F. (3S.3° C.) for one day. In the first 
group the morbidity was greater by 7 per cent in panhysterectomy; in the second 
group supravaginal hysterectomy had a greater morbidity by 2.S per cent, whereas 
in the last group the morbidity for both was exactly the same, IS. 8 per cent. In 
general there is a slight decrease in morbidity. In the vaginal hysterectomies 
there was no morbidity in the second group. In the third group it was 11.5 per 
cent, which is 7.4 per cent less than it was in the abdominal hysterectomies of the 
same period. 


the eases after the menopause as compared ivith 9 per cent of the supra- 
vaginal, shelving that in the younger group of ivomen an attempt vas 
made to conserve the cervix. Hysterosalpingectomj’" (Beuttner opera- 
tion) was performed for pelvic inflammation in young women, where the 
tubes showed such pathologj’’ that it was deemed unwise to conserve them, 
hut the ovaries were healthy enough to be retained. The function of 
menstruation was therefore retained, although it was necessary to sacri- 
fice the function of reproduction. It is interesting to note that 75 per cent 
of these patients had had more than one child, 12.5 per cent one child, and 



PHANEUF AND BEDSON: I1VSTERECT03IIES 


265 


12.5 per cent no cliildren. The vaginal hs^sterectoniies were performed 
on mnltiparons women in 86 per cent of the cases and 54 per cent of the 
patients so operated upon were beyond the menopanse. 


Table II. Age Table 


AGES 

18-19 

20-29 

30-39 

40-49 

50-59 

60-09 

AA'ERAGE 

AGE 

NO. 

PER 

CENT 

NO. 

PER 

CENT 

NO. 

PER 

CENT 

NO. 

PER 

GENT 

NO. 

PER 

CENT 

NO. 

PER 

CENT 

Panliysterectomy 



8 

4.4 

46 

25.5 

88 

48.8 


16.0 

8 

4.4 

42.56 

Supravaginal 

5 

1.0 


16 

124 

40.1 

1 


35.5 


6.4 

2 

0.6 

37.77 

Vaginal 




2.8 

3 

8.5 

11 

31.4 

6 

17.1 

14 

40 

51.65 

Porro cesarean 






i 








section 





3 

75 

1 

25 





35.5 

Hysterosalpingectomy 



3 

37.5 

5 

62.5 

! 






31.0 

Wertlieim 





5 

71.4 

2 

28.0 





37.2 


Table II shows that the average age of the women who had vaginal 
h 3 ’'sterectomies was 51.65 years, indicating that this method was largelj’’ 
used in older women. Those who had panhj^sterectomies had an average 
age of 42.56 years, while the average age of the patients who had supra- 
vaginal hysterectomies was 37.77 j’-ears, denoting an attempt at conserva- 
tion of the cervix in the j^ounger women. The hysterosalpingectomies 
(Beuttner) were performed on women whose average age was thirtj’-one 
years, because we felt it was important to conserve the function of men- 
struation. 

We have grouped in Table III the five most common sjunptoms com- 
plained of. By pain we mean any lower abdominal pain or discomfort. 
Abnormal bleeding refers to menorrhagia or metrorrhagia or both. Ab- 
dominal tumor means that the patient complained of a mass in the abdo- 


Table III. Percentage of the Pive Most CojtJioN SvArPTOJis 



PAIN 

1 ABNORMAL 

1 BLEEDING 

ABDOMINAL 

TUMOR 

VAGINAL 

TUSrOR 

LEUCOR- 1 

RHEA 

URINARY 

Panliystcrectomy 

56 

70 

9 

2 

30 

9 

Supravaginal 

76 

52 

11 

5 

30 

13 

Vaginal 

20 

54 

0 

54 

20 

17 

Hysterosalpingectomy 

100 

25 

0 

12 

75 

0 

Wertheim 

28 

56 

0 

0 

71 

0 










266 


A^IERICAX JOURNAL OF OBSTETRICS AND GYNECOLOGY 


Table IV. Previous Lapakotojit 


Panh3-stercctoni3' 

Per cent 
18 

Supravaginal 

30 

A''aginal 

17 

Porro cesarean section 

25 

H 3 ’sterosalpingectoiny 

25 

Wertheim 

0 


Table V. Association of Perineal Opehations With HYSTERECxoiiv 



laparotomy 

LAPAROTOMY 

AND PERINEAL 

SIMPLE* 

COMPLICATED 

SIMPLE 

COMPLICATED 

NO. 

per 

CENT 

NO. 

PER 

CENT 

NO. 

PER 

CEXT 

NO. 

PER 

CENT 

Panhysterectoiny 

100 

56 

50 1 

28 

17 

B 

13 

7 

Supravaginal 

110 

34 

150 

47 

19 

1 

B 

41 

13 

Porro cesarean section 



4 

100 


B 



Hysterosalpingectomy 

1 

12 

O 

25 



5 

63 

Wertlicini 



7 

100 


B 




‘Simple = Single anatomical oi- pathologic defect. 
Complicated = More than one. 


Table VI. Operative Complications 



1915-1919 

1920-1924 

1925-1931 


PAN. 

SUPRA- 

VAGINAL 

PAN. 

SUPRA- 

VAGINAL 

VAGI- 

NAL 

PAN. 

SUPRA- 

VAGINAL 

VAGI- 

NAIi 

Bladder injured 

1 

1 

1 

1 

! 

1 

1 



1 

1 


Bowel injured 

2 

1 


1 




1 


Uterus torn from 
cervix 

■ 



1 


1 

1 

1 

1 

j 


Heart 









1 

Ureter constricted 

■ 




j 




1 


4 or 
4.7% 

2 or 
1.9% 

0 

2 or 
2.3% 

0 

1 or 
1.8% 

2 or 
1.4% 

1 or 
3.8% 


Total Years: 

Panliysterectomy 5 or 2.7% 

Supravaginal hysterectomy 6 or 1,8% 

Vaginal hysterectomy 1 or 3.8% 


































PHANKUF AND BELSON: HVSTERECTOJIIES 


267 


meii. Vaginal tumor denotes any prolapse or bulging at the vaginal in- 
troitus. Leucorrliea and urinary symptoms are self-explanatory. The 
percentage of bleeding vas greatest in the panliysterectomies, being men- 
tioned in 70 per cent as compared with 52 per cent in supi'avaginal and 54 
per cent in vaginal hysterectomies. Pain was most common in the hys- 
terosalpingeetomy group, being present in 100 per cent of; the cases. 
Vaginal tumor or bulging was found in 54 per cent of the vaginal pro- 
cedures. Leucorrliea was the second symptom in prominence in the 
h 3 ’stez’osalpiugeetoniies occurring in 75 per cent of them. 

Previous laparotomies had been performed in IS per cent of the panhj’’S- 
tereetomies, 30 per cent of the supraAmginal hj^sterectomics, and 25 per 
cent of the hysterosalpingeetoniies, showing that an attempt at conserva- 
tion had been made without relieving the s.vmptoms. 

Table V presents the association of perineal operations with hj’S- 
terectom 5 \ Simple laparotomj' refei's to a single anatomical or iiath- 
ologic defect, while a complicated laparotomj’- refers to more than one 
defect. In the panhj'sterectomies, 56 per cent were simple and 28 per 


T.vble VII. Postoperative Complications 



1910-1919 

1920-1924 

1 . . 

1925-1931 

PAN. 

SUPEA- 

VAGINAL 

PAN. 

1 SUPRA- 
VAGINAL 

VAGI- 

NAL 

r.\N. 

SUPRA- 

VAGINAL 

VAGI- 

NAL 

Ileus 

n 

2 




1 

1 


Peritonitis 


1 







Pulmonary embolus 


2 







Shock 

4 

1 


2 , 





Incisional abscess 

1 








Separation of in- 









cision 


1 


1 



2 


Phlebitis 

1 



1 , 



1 


Intestinal ob- 




j 





struction 



1 






Myocarditis 



2 






Pneumonia 


2 


1 



1 


Incisional hernia 

1 








Pelvic abscess 

1 






1 


Furunculosis 

1 






1 

i 

Liver abscess 

1 





! 



Anuria 







1 


Pecal fistula 









Postoperative in- 



i 

1 

1 



1 


sanity 


1 





1 



12 or 

9 or 

3 or 1 

5 or 

0 

1 or 

5 or 

1 or 


14% 

8.6% 

7.1%| 

5.7% 


|l.88% 

1 

3.9% 

3.8% 


Total Years: 


Panhystereotomy 10 or 8.8% 

Supravaginal hysterectomy 19 or 5.9% 
Vaginal hysterectomy 1 or 3.8% 
















268 


A5IERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


cent were eoinplieated as compared with 34 per cent simple laparotomies 
and 47 per cent complicated in the supravaginal. It is evident from this 
that in the supravaginal group there were more complicated anatomical 

Table VIII. Operative Procedures 



PAN- 

UTSTER- 

ECTOMY 

SUPRA- 

VAGI- 

NAL 

VAGI- 

NAL 

tVER- 

THEIM 

PORRO 

CESAREAN 

SECTION 

HYSTERO- 

SALPIN- 

GECTOMY 

Panliystcrcctomy 

180 


1 




Supr.iv.ngiiial hysterectomy 


320 





Vaginal hysterectomy 



35 




Wertheim radical hysterectomy 

j 

1 

1 

7 



Porro cesarean section 





4 


Hysterosalpingectomy 


1 





(Beuttner) 






8 

Salpingectomy, double 

154 

246 

7 


3 


Salpingectomy, single 

10 

36 

2 




Oophorectomy, double 

151 

235 

7 


3' 


Oophorectomy, single 

15 

40 

2 

1 

'■ ! 

1 

Appendectomy 

C8 

137 


1 

1 1 

5 

Cystectomy, parovarian 


1 


] 



Ovarian transplant 

1 

8 





Bowel repair 

2 1 

3 





Bladder repair 

1 

3 





Cholecystectomy 

1 

1 





Drainage of pelvic abscess 

1 i 






Obliteration of culdesac of 







Douglas (Moschowitz) 


3 





Herniorrhaphy, ventral 


3 





Herniorrhaphy, umbilical 

3 

1 





Hcrniorrhaplp'’, inguinal 

1 






Herniorrhaphy, femoral 


1 





Citrate transfusion 

11 

9 


1 j 



Intestinal resection and 







anastomosis 


1 





Cecostomj' 

1 

1 





Gastroenterostomy undone 


1 




0 

Curettage 

24 

34 

1 




Cauterization of cervix 


9 




' 5> 

Amputation of cervix 


8 

* 




Trachelorrhaphy 


12 





Anterior colporrhaphy 

2 

14 

4 


1 

i 2 

Per ine or rh aphy 

6 

23 

24 


1 


Third degree perineorrhaphy 



1 




Vaginal myomectomy 


1 





Interposition of broad liga- 







ments 



13 




Fixation of broad ligaments 







to vaginal cuff 



1 






defects. The association of perineal operations with the lapai otomy v as 

almost equal in both groups of cases. 

Dividing the eases in three periods, we find a decrease of complications 
in the last period. They were, as sliowii in Table VI, 1-8 per cent for t le 
total hysterectomy and 1.4 per cent for the subtotal. The complications 
were essentially bladder and bowel injuries. In the vaginal hjsterec 









PHANEUF AND BELSON: HYSTERECTO^IIES 


269 


tomies there "were uo operations in the first period, there 'svere no compli- 
cations in the second period, and one complication or 3.8 per cent in the 
third period, Avhich was the constriction of an anomalous ureter. 

Table VII shows that the postoperative complications in the panhys- 
terectomies, which were greater than in the subtotal in the first two 
periods, became less than those of the supravaginal in the last period, the 
ratio being 1.88 per cent for the total against 3.9 per cent for the subtotal. 
In considering the whole group the A'aginal hysterectomy has the least 
number of postoperative complications. 

Table VIII shows that in 180 panhystereetomies 451 additional pro- 
cedures were done. In 320 supravaginal hysterectomies 842 supple- 
mentary operations were recorded. In 35 A'aginal hysterectomies we find 
62 additional procedures. In 7 "Wertheim radical dissections the only 
addition was a preoperative blood transfusion. In 4 Porro amputations 
there were 8 additional operations, while in 8 hj’^sterosalpingeetomies 
there were 15. 

Table IX presents the chief operative diagnoses in the various groups 
and is self-explanatory. The 16 panhj’sterectomies for carcinoma of the 
cervix had had previous radium treatment. 

Table X reports the additional operative diagnoses. These are apparent 
and need no comment. 


Table IX. Chief Opebative Diagnoses 



PAN- 

HYSTER- 

ECTOMT 

SUPRA- 

VAGI- 

NAL 

VAGI- 

NAL 

WER- 

THEIM 

PORRO 

CESAREAN 

HYSTERO- 

SALPIN- 

GECTOMT 

Chronic pelvic inflammation 

18 

i 120 



1 

4 

Chronic salpingitis 

2 

1 3 

1 



4 

Pelvic abscess 


! 2 

1 




Myomata uteri 

87 

158 

2 


1 ' 


Fibrosis uteri 

2 

6 

1 2 




Hypertrophic endometritis 

6 

2 

1 




Hyperplastic uterus 

6 

7 





Essential menorrhagia and 




1 


1 

metrorrhagia 

12 

11 





Placenta acereta 


1 

1 ^ 




Inverted puerperal gangrenous 






I 

uterus 

1 


1 

1 


j 

Infected pregnant uterus -with ^ 







cephalopelvic disproportion 

1 




3 


Ruptured ectopic pregnancy 

2 

5 


i 



Ruptured uterus 

1 

2 < 





Endometriosis 

1 

7 ' 





Carcinoma of ovary 

1 



1 



Ovarian cyst (dermoid) 

2 

1 





Ovarian cyst (benign) 

21 

51 

1 




Parovarian cyst 


1 1 





Carcinoma of fundus uteri 

25 






Carcinoma of cervix uteri 

16 






Cervical polyps 

4 


1 

1 



Procidentia 



26 















270 


AJIERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


Table X. Additional Opebative Diagnoses 



I'AN- 

HYSTEU- 

ectomy 

SUPRA- 

A'AGl- 

NAL 

vagi- 

nal 

■\VEU- 

PORRO 

CESiVREAN 

HYSTERO- 

SALPIN- 

GECTOMY 

Eectocele 


21 

8 




Eelaxed perineum 

6 


1 



1 

Enterocele I 


3 





Cystocele ! 

1 

12 

O 



1 

Lacerated cervix 

Itl ’ 

17 

8 

! 


3 

Erosion of cervix 

10 

O 

O 




Cystic glands of cervix 

O 






Prolapse of uterus 

2 ' 

12 





Eetroversion of uterus 

o 

4 





Chronic appendicitis 

13 

28 





Cholelithiasis 


7 





Diabetes 


1 

1 




Tabes dorsalis 







Euptured corpus luteuin Avith 







hemorrhage 

1 

2 

1 


1 


Hernia, ventral 

1 

3 





Hernia, umbilical 

3 

1 


' 



Hernia, inguinal 

1 

2 





Hernia, femoral 


1 





Uterus bicornis, bicollis 


1 






SUMMARY 

1. There are 554 h.vstercetomies of all types reported as folloivs : 180 
panhystereetomies, 320 supravaginal, 35 vaginal, 7 'Wertheim, 4 Poito 
and 8 hysterosalpingectomies (Beuttner). They are grouped in three 
periods. 

2. In our last group of cases, covering the years 1925 to 1931, the mor- 
tality of panhystcrectomy has been half a per cent lover than that of 
supravaginal. 

3. In this same period of time the morbidity for the tvo methods has 
been exactly the same. 

4. Vaginal hysterectomy is an ideal method in older vomen vhere suf- 
ficient relaxation of the vagina exists to give easy access to the pelvic 
organs. 

5. The chief symptoms for which the operation was performed were 
pain, hemorrhage, and tumor. 

6. The average age of the patients Avho had irnginal hysterectomies ivas 

51.6 j'^ears, iianhysterectomies 42.5 years, supraA’’aginal hysterectomies 

37.7 years, Avhile the hj^sterosalpingectomies, (Beuttner) were performed 
on Avomen Avhose aA’^erage age Avas thirty-one years. 

270 Commonavealth Aat:nue. 

ABSTEACT OF DISCUSSION 

DE. JAMES F. BALDWIN, Columbus, Ohio.— My particular interest is to empha- 
size the importance, in practically all eases of hysterectomy, of removing the cervix. I 
knoAV or more than forty cases in which, after supracervical amputation, cancer devel- 















PHANEUF AND BELSON : HYSTERECTOJIIES 


271 


oped in the cervix. In all of these cases the disease appeared long after the original 

operation. . 

The unrcinoved cervix is liable, particularly in wonieii who have borne children, to 

develop cancer, is frequently the source of an annoying leucorrhea, and sometimes of 
pronounced dyspareunia. In one of my eases the cervix, which had been left bclnnc 
after a panhysterectoniy by a Birmingham surgeon twenty-five years before, had be- 
come the starting point of a very ugly mass of fibroids, quite filling the pelvis and 
weighing more than four pounds. The cervix itself was scarcely larger tlmn the last 
joint of the little finger, but these fibroids had sprung from the upper end. 

That a nulliparous cervix is less liable to make trouble than a multiparous one, is ad- 
mitted; but no remnant cervix is without ample possibilities of disease, is of no pos- 
sible use, and its removal as a prophylactic measure is clearly indicated. I have been 
obUged in a number of instances to remove through the vagina the cervix that had thus 
been left; and such removal is infinitel}’ more difficult, more time-consuming and vastly 
more dangerous than its removal at the original operation. 

With the proper exposure of the pelvis by the Trendelenburg position, and care to 
see that the bladder has been previously emptied, it would seem to be practic.ally im- 
possible in any way to injure the bladder, ureter or bowel; and with peritoncalization 
as advised, intestinal obstruction would .apparently be entirely out of the picture. This 
statement is based on a personal experience of over 6000 hysterectomies. On a verj’ 
few occasions it was found necessary to remove the lower end of a ureter involved in the 
cancerous growth, and to implant the proximal end in the bladder; these cases all did 
well. On one occasion the cancer had so involved the right ureter that its excision left 
the ureteral stump too short for implantation into the bladder. The ureter was there- 
fore ligated tightly with silk and dropped. The patient made a fine operative recovery, 
but died of cancer a little more than a year later. Autopsy showed that death had oc- 
curred from metastasis to the retroperitoneal glands, but there was no involvement 
whatever of the pelvic tissues. The kidnej', which had given no trouble whatever, was 
found somewhat eontracted and with a slight dilatation of the ureter above the ligature. 

In another case, of similar character, a large portion of the left ureter was exposed 
in removing the cancerous tissue. Tim uninjured ureter was carefully covered with 
peritoneum but there had been too great an interference with the blood supply and a few 
days later a ureterovaginal fistula developed, provision for which had been made by a 
little drainage wick. The patient made a good recovery, but in due time it seemed wise 
to remove the kidney ; this was done without difficulty and with complete, though neces- 
sarily not lasting, convalescence. 

A few suggestions as to technic may be in order. So far as I can learn few operators 
take pains, at least the pains that I always take, to sterilize the vagina before opening 
the abdomen. The danger of infection coming from the vagina is of such vital im- 
portance that I never trust the cle.insing to an assistant. I rvash out the vagina 
thoroughly personally rvith tincture of green soap and hot w.ater, being careful to 
thoroughly reach every part. Then, lest infection might enter the vagina from the 
uterine cavity, I catch the anterior lip of the cervix with a volsellum and fill the uterine 
cavity wdth full strength tincture of iodine by means of a special pipette. Some of this 
iodine runs back into the vagina, but I at once flush the entire vagina with one-fourth 
strength tinetiue of iodine, so that I can look upon that entire area as well sterilized, 
and its sterility, I think, has been demonstrated by tlie fact that I have never had a 
peritonitis coming from that source. 

Another very important feature of the operation, after attaching the ligaments to 
the vault of the vagina, is, as the author states, the peritoncalization of all bare sur- 
faces. Tins can usually be done by bringing over adjacent peritoneum, but in some 
cases can only be done by leaving the vagina open and passing into it the ends of three 
strips of iodoform gauze, each strip a yard long and 12 inches wide, with the raw edges 
turned in so as to avoid ravelings. The rest of the strips are then carefully placed so as 



272 


AiCERICAN JOURNAL OF OBSTETRICS AND GTNECOLOGV 


to fill the true pelvis, and over these the sigmoid is swung around and attached hy a 
continuous suture to the brim of the pelvis. There is thus no raw surface left exposed. 
This gauze fluff is left undisturbed for one week, and then is easily withdrami bv catch- 
ing the laginal ends. The use of thjs gauze fluff obviates all fear of postoperative ad- 
hesions and postoperative ileus. (This method of utiUzing the sigmoid was introduced 
by Dr, J. E. Summers, of Omaha, Neb., Surgery, Gynecology and Obstetrics, August, 
1911.) 

Generally only four ligatures are necessar}', one on each uterine and one on each 
ovarian artery. Oceasion.allj- some branch will require a ligature; but, as I demon- 
strated by dissection a good many years ago, the round ligament arteries with the rarest 
possible e.xccption never need ligation. 

I see no reason for making a two-stage operation of a hysterectomy, removing the 
cerri.v at the first and a few weeks later subjecting the patient to a second operation for 
removal of the body of the uterus. The removal of the cervi.x by an experienced opera- 
tor will require but an additional minute or two, and frequentl 3 ’ will require less time 
than to properly implant the ligaments into the cervix and pcritoncalize the field of 
operation. 

In all ordinal-}- hysterectomies, the vault of the vagina should be closed by a purse- 
string or transverse continuous suture catching the submucous tissues, followed by a 
continuous suture bringing the peritoneum together. No provision for drainage is 
necessary. In women under forty it is usually desirable, if tho organs arc healthy, to 
leave tho tubes and ovaries, or at least one ovary. Leai-ing the tubes saves a little time 
and gives a bettor blood supply to tlic ovaries. These appendages should be attached 
high up on each side of the pelvis, so as to avoid any possibility of dyspareunia which 
is so apt to occur if they are allowed to drop, as is so frequently the case, to tho bottom 
of the pelvis. 

Tho death rate in ordinary hysterectomy should not exceed 1.5 per cent, but in cases 
of malignancy or preexisting infection the death rate will necessarily be higher. 

DE. P. B. BLAND, Pnri,aDELPHrA, Pa . — While there is still some controversy with 
regard to supravaginal versus complete hysterectomy, I personally perform the less 
formidable operation whenever possible, because the operation is infinitely easier to 
perform and the results both immediate and remote are far better than after the major 
operation. 

My personal records of gynecologic operations show, in 1500 consecutive operations, 
202 hysterectomies, an incidence of 1.3 per cent. These included 146 supravaginal op- 
erations, 26 complete operations and 30 vaginal operations. The age of the patients 
varied, the youngest being 25 and tlie oldest 71. The average ranged from 25 to 40. 
There were 8 deaths, a mortality of 3.9 per cent, divided as follows; After supravaginal 
operation 4; after complete hysterectomy? 3 > after vaginal operation, 1, or 3.10 per cent. 

In one hospital I covered the clinical records of 3103 gynecologic operations and 
found that 298 hysterectomies were performed, an incidence of something less than 
1 per cent. These included 221 supravaginal, 52 complete, and 25 vaginal operations. 
The age of the youngest patient -was eight and the oldest seventy-one. In the SOS 
hysterectomies performed there were 11 deaths, a mortality of 3.7 per cent, divided as 
follows : after supravaginal 3 ; after the complete operation, 3 ; after the vaginal pro- 
cedure 5. 

DE. JAMES B. KING, Buffalo, N. Y.— The discussion has apparently focused 
upon the question of whether panhysterectomy or the supravaginal method is prefer- 
able. Bor me that has not, in recent years, been a problem because 1 believe that the 
diseased cervix, excluding carcinoma, of course, can be taken care of satisfactorily -with 
the cautery. 

My big problem has been with the patients who have not reached the menopause. In 
such cases it has been my practice in doing a supravaginal operation to leave tho ovaries. 



PHANEUF AKD BEESON: HYSTEKECTOIMIES 


273 


My experience ’svith some of these patients has been unfortunate as they liave returned 
to me with ovarian cysts or other ovarian conditions which have required operation. 
This occurred in spite of the fact that at the first operation tlie ovaries were apparently 
perfeetlj' normal according to the operative report. 

DR. GEORGE GELLHORN, St. Louis, Mo.— Dr. Dhaneuf has shown convincingly 
that to him who takes the trouble of perfecting his technic, total abdominal hysterec- 
tomy is attended with no greater danger than the siqn-avaginal operation, and I am in 
hearty accord with that idea. I was even more pleased with the emphasis laid upon 
vaginal hysterectomy. The value of vaginal h 3 'stereetomy cannot be overestimated; 
yet, this operation has not become popular among gynecologists. This is all the more 
surprising as major vaginal operations rc.ally originated in this countrj-. Robert Bat- 
tey of Rome, Georgia, in 1876, was the first to approach the genital organs through the 
vagina. His example was followed a decade or so later in Germany where the technic 
of vaginal operations was extended to a high degree of perfection. In America, how- 
ever, these operations have fallen into disuse, and the present generation of young 
gjmeeologists grow up without receiving instruction in this particular field. This is 
rather deplorable because the advantages of vaginal over abdominal operations are in- 
disputable in a large number of cases. 

DR. JAMES W. KENNEDY, Philadelphia, Pa. — At present I remove the uterus 
by the vaginal route, clamp method, in about 95 per cent of the cases. At this moment 
I am rviUing to go on record bj' the prophecy that in the future there will be a greater 
number of vaginal hysterectomies performed. 1 have given up the ligature method of 
performing the vaginal hysterectom}’ and have adopted the clamps in the removal of 
the uterus. The clamp method will increase the percentage of operability to a marked 
extent. 

It is very much more thorough from the standpoint of tissue removed than the liga- 
ture method and therefore we have adopted it in the malignant conditions of the uterus. 
The slough which follows the clamp method of vaginal hysterectomy occurring on about 
the twelfth postoperative day is, in our opinion, a very important and eventful influence 
in its splendid results in the surgical treatment of the malignant uterus. 

The death rate of vaginal hysterectomj', clamp method, has been in our experience in 
the Joseph Price Hospital a fraction of one per cent. 

DR. JAMES E. DAVIS, Ann Arbor, Michigan. — The controversial points involved 
in hysterectomy would be cleared if the selection of cases were the same by the different 
operators. In the group of cases studied by me a couple of years ago and reported be- 
fore this Association a number of uteri were removed where there was no indication for 
the removal except a slight hj-pertrophy or metaplasia of the myometrium. A study of 
these cases in a large percentage of instances would have shown the pathology was in 
the ovary, or in the ovary and the pituitary. The endometrium is under the control of 
the ovary and possibly the pituitary. These uteri could be left alone and a number of 
deaths obviated, especially in the hands of the inexperienced operators. 

Important points have already been made in regard to the indications for the re- 
moval of the cervix. It is worthwhile to emphasize the thought that if there is no in- 
fection, if the appearance indicates that the cervix is without pathology, then perhaps 
it could be safely left. If the cervix is lacerated, as is the case in the vast majority of 
instances, there will be found also erosion and infection, then removal or destruction of 
the endometrium should be accomplished. By so doing one adds a great measure of 
prevention against malignancy. 

DR. E. S. -WETHEBELL, Syracuse, N. T.— With the increased use of spinal anes- 
thesia, a danger which is often lost sight of is that ivith a relaxed rectal sphincter and 
with the patient in the Trendelenburg position, some fecal material might be evacuated 
and travel into the vagina. VTien spinal anesthesia is used, the vagina should invari- 
ably be packed before the abdomen is opened. 



PLACENTA ACCRETA^ 


Conservative Versus Eadicau Treatment, With a Report of 

Three Cases 

E. Lee Dorsett, M.D., St. Louis, Mo. 

TDLACENTA aeereta is a definite pathologic entity and should not he. 

confused with retained placenta or adherent placenta. Polak states 
that in his experience it has occurred once in 6000 cases, while Foster of the 
j\Iontreal Maternity reports it occurring once in 8000 eases. It is not the 
rarity of this condition that has prompted the report of these cases, but to 
bring out the fact that delay in diagnosis and treatment leads to disastrous 
results. The three cases here presented illustrate the condition from three 
different angles ; the too conservative treatment ; the conservative treat- 
ment at first, followed by radical treatment; and lastly, the immediate 
radical treatment. 

The anatomic histologic picture of placenta accreta shows a more or less 
absence of the spongj’’ layer of the decidua basalis. The villi penetrate the 
uterine muscle and in some areas become a part of the musculature ; a num- 
ber of cases have been reported in which the penetration has been down to 
the peritoneal covering of the uterus. 

J. N. Nathanson is of the opinion that atrophy of the endometrium is a 
predisposing cause and also that the improper development of the corpus 
luteum causes a limited development of the decidua. It seems to be the 
consensus of opinion among the UTiters that a previous eurettement is a 
cause of this condition and this point is brought out in the history of two 
of the eases herein reported. Previous pregnancies and manual removal 
of the placenta in other pregnancies have a bearing in causing this condi- 
tion. All three of these cases were multiparous women, but none gave his- 
tory of adherent placenta. 

Experience shows how futile it is to try to remove the placenta or a 
gi’eater part of it, from its implantation on and in the uterine wall, with- 
out a most severe hemorrhage or if the tissue is not all removed, an infec- 
tion follows in an already exsanguinated patient. Where we are deal- 
ing with air adherent placenta, there is a definite decidua basalis pres- 
ent, and the placenta has not become more or less a part of the uterine 
muscle, so that when the hand explores the uterine cavity in an attempt to 
remove the placenta a definite line of cleavage is found, and it can readily 
be stripped from its attachment. 

A great many of us are to be critized as to the management of the third 
stage of labor. We are anxious to finish our case, and by too violent mas- 

*Eead at the Forty-Fifth Annual Meeting- of the American Assomation of Ob- 
stetricians, Gynecoiogists and Abdominal Surgeons, French Lick Springs. Ina., 
September 12, 13, and 14, 1932. 


274 



DORSETT: PLACENTA ACCRETA 


275 


sage on tlie fiindns, or retraction on tlie cord, or both, we hasten the third 
stage of labor. Jnst how long to wait before the placenta is expelled is a 
matter of personal opinion, but it seems to be an unwritten law that the 
placenta should be expressed at the end of twenty minutes. There should 
be no difficulty in recognizing a retained placenta but an adherent placenta 
and placenta acereta can only be diagnosed wheir the hand is introduced 
into the uterine cavity. A disturbance in mechanism is the underlying 
factor in the delay in the separation of an adherent placenta, but, as before 
stated, placenta accreta is entirely pathologic. 

When it has been decided that a manual removal of the placenta is indi- 
cated, it should be done with the utmost care and having in mind the fact 
that if a definite line of cleavage cannot be determined, there is a placenta 
accreta present that cannot be remor'ed. furthermore if an attempt is 
made to remove it the patient Avill suffer from shock and hemoiThage, or 
the uterus maj' be perforated. In all of the eases reported here, an attempt 
was made to remove the placenta. Large pieces were removed, and in all 
cases this maneuver was followed by terrific hemorrhage. In the first case 
four attempts were made to remove the placental tissue without satisfac- 
tory results. Each time the patient had a hemorrhage, was packed, and re- 
quired blood transfusion. A dull curette was used but very unsuccessfully 
because of the fear of perforating the uterus. This case developed sepsis 
and a pelvic abscess. The abscess was drained and after seven weeks the 
patient made a good recovery. 

The second ease had two attempts at removal of the placental tissue, 
was packed, had blood transfusions, and an unsuccessful attempt was made 
to ligate the uterine arteries from below. On the fourth postpartum 
day a total hysterectomy was performed, hut the patient died of general 
pei’itonitis. 

The third case was a patient thirty-six years old who had borne four 
children, had six abortions, four of the abortions requiring a curetteraent. 
In her last pregnancy she complained of constant uterine pain and on 
numerous occasions had severe uterine contractions. Her labor was pre- 
cipitate at full term, a breech presentation with a prolapsed cord. A living 
baby was delivered, but after waiting forty-five minutes, an attempt was 
made to expel the placenta by the usual methods. This was lursuccessful, 
so a manual removal was decided upon. When the hand was introduced 
into the uterus the placenta was found to he firmly adherent with no line 
of cleavage present. Several large pieces were torn loose from the uterine 
wall followed by a copious hemorrhage. The uterine cavity was packed 
and the patient returned to bed and transfused. The patient was allowed 
to rest several hours and then was removed to the operating room and a 
supracervical hysterectomy was performed and the patient again trans- 
fused. This patient made a most remarkable recovery and left the hospital 
on the twelfth postoperative day. 

TJie one successful ease herein cited camrot he held up as being the cor- 



276 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


rect iBcthocl by ■whicli to treat this couditiou. The cases are so few and far 
between that even with all the eases collected and reported, we conld not 
then pass judgment. From the meager reports so far found in the litera- 
ture, there seems to be no doubt in the opinion of the wTiter that an im- 
mediate hysterectomy is indicated. 

Klopten reports 46 eases with a mortality of 87.5 per cent when they 
were conservatively treated, as compared to 14.3 per cent when treated 
radically (by hystcrectom.y)- 

CONCLUSIONS 

1. The three eases here presented are examples of conservative, and de- 
layed radical treatment and immediate radical treatment. 

2. "^^Tiere no line of cleavage is present, and it is impossible to remove 
the placenta, hysterectomy should be performed as soon as possible. 

3. Blood transfusion where there is severe hemoiThage is of the utmost 
importance. 

CASE HISTORIES 

Case 1. — A woman, twenty-two years old, had one child two years previous to this 
pregnancy. At this time she had eclampsia. Entered hospital with history of one con- 
vulsion and only had one more after the intravascular injection of magnesium sulphate. 
At the time of her first delivery she had a third degree laceration of the perineum. It 
failed to heal and was subsequently repaired. August 6, 1924, she again entered the 
hospital in labor but two months premature. She delivered spontaneously of a 1820 gm. 
baby (died on the eleventh postpartum day). An attempt was made to express the 
placenta, but the usual method failed so a manual removal was attempted. No line of 
cleavage was found, and wrongly an attempt was made to remove the placenta piece- 
meal, with the result that the patient verj’ nearly bled to death on the delivery table. 
The uterine cavity was packed, the patient returned to bed, 750 c.c. of citrated blood 
given intravenousl}'. On the following day another attempt was made to remove the 
remaining pieces of placenta with a curette, but this was not very successful, .and the 
patient again bled very profusely, was packed, and transfused. The packing was re- 
moved in tw'enty-four hours, and hemorrhage followed. She was again repacked and 
transfused. This procedure was again attempted on the folio-wing day with the same 
results and treatment. Tlie fifth day very- little hemorrliage followed the removal of the 
packing, but the patient began showing signs of sepsis and developed a pelvic cellulitis. 
A pelvic abscess developed, followed by operation four weeks after delivery. After a 
very stormy convalescence the patient recovered and left the hospital seven weeks after 
labor. 

Case 2. — Patient, aged thirty-five, gravida 4. Entered hospital in labor at full term. 
Had one abortion previous to this pregnancy and was curetted. In labor thirteen hours- 
and delivered spontaneously of a living child. The placenta did not separate and an at- 
tempt was made to remove it manually. About half of the placenta was removed, but 
further attempt was impossible due to severe bleeding. The uterus was packed and the 
patient transfused. The following day an attempt was made to remove the remaining 
remnants of placental tissue with a dull curette, but this was not successful due to hem- 
orrhage. The uterus was again packed and patient again transfused. Later in the day 
an attempt was made to ligate the uterine arteries per vaginum, but when the uterine 
packing was removed the bleeding was so profuse that the uterus w’as repacked and the 
patient prepared for a laparotomy. Operation; hysterectomy. The patient was trans- 
fused before and after the operation, but developed peritonitis and died on the eighth 



DORSETT : PLACENTA ACCRETA 


277 


postpartum da}'. (I am indebted to Dr. Sam Abrams of St. Louis for allowing me to 
report this case.) 

Case 3.— Patient, aged thirty-six, gravida 12. Had four living children, two pre- 
mature labors at six months, and seven abortions (none induced). Patient and hus- 
band both had negative Wassermanns. During the last three months of her pregnancy 
the patient had almost constant uterine pain and irregular uterine contractions, and on 
two occasions went to the hospital thinking she was in active labor. On April 25, 1932, 
she reentered the hospital with a history of having had irregular contractions all night. 
Upon examination it was found that it was a breech presentation and vaginal examina- 
tion revealed two finger dilatation. At 9:15 a.m. a hj-podermic of 2 mm. of inf undin 
was given. This increased the contractions, for a short time and the dose was repeated 
in one hour. This last injection was followed by very active contractions and in twenty 
minutes the membranes ruptured. When the patient arrived in the delivery room one 
foot and the cord had prolapsed. Under ether a living child was delivered easily. Ke- 
peated efforts with Credo’s method failed. A manual removal was then decided upon, 
but when an attempt was made to remove the placenta, no definite line of cleavage was 
found, and wrongly an attempt was made to remove the placenta piecemeal. Immedi- 
ately very copious hemorrhage resulted, and the uterus was packed, the patient given 
750 c.c. of citrated blood and returned to bed. Por several hours the patient showed evi- 
dence of shock but when these symptoms subsided she was taken to the operating room 
and a supravaginal hysterectomy was performed (both tubes and a cystic right ovary 
were removed at this time) ; 750 c.c. of blood was again given following the operation, 
and the patient showed no shock after returning from the operating room. She made 
an uneventful recovery and left the hospital on the twelfth day. 

Examination of the uterus showed the endometrial surface was ragged and irregular, 
and in one portion was attached a large shaggy mass of placental tissue which repre- 
sented the remains of the placenta accreta. 

Histologic examination showed at the junction of the villi and the uterine muscle, 
only a small amount of decidual tissue and no spongy decidua anywhere. In many 
areas, only a thick layer of fibrin was interposed between the villi and muscle. The 
uterus away from the placental site showed a few decidual cells and underlying them 
considerable blood. With 0. V. stain, the intima of the vessels was seen to show early 
edematous changes. 


REFERENCES 

(1) Polafc, J. C., and Phelan, G. TV.; Surg. Gynec. Obst. 38: 181, 1924. (2) Foster, 
D. S.: J. Canadian M. A. (3) Nathanson, J. N.: Am. J. Obst. & Gynec. 16: 44, 1928. 
(4) TVilUams; Obstetrics, ed. 6, 1930, D. Appleton and Company. (5) Queen’ Char- 
lotte’s (Hospital) Practice of Obst. (6) Lehmann, E.: Monatsehr. f. Geburtsh n. 
Gynak. 68: 201, 1925. (7) Dietrich, H. A.: Ztschr. f. Geburtsh u. Gyniik. 84: 579, 

1922. (8) Tiemeyer, A. C.: Am. J. Obst. & Gynec. 22: 106, 1931. {Q)Asdhermann, 
G.: Monatsehr. f. Geburtsh. u. Gyniik. 78: 75, 1928. (10) Frank, F. T. ; Am. J. Obst. 
& Gynec. 12: 585, 1926. (11) De Lee, Jos.; Practice of Obstetrics. (12) Eden and 
Solland; Textbook of Obstetrics, New York, 1925, The Macmillan Company. 

634 Noeth Grand Boulevard. 

AESTEACT OP DISCUSSION 

DE. PEEDEEICK H. PALLS, Chicago, III. — I have seen three of these cases. The 
first one was in consultation on about the eighth day of the puerperium with the patient 
almost exsanguinated from a continuous dribbling of blood. Attempts had been made 
after delivery to remove the placenta but they were only partially successful. Because 
of the anemia of the patient and some fever, I rather hesitated to open the abdomen. I 
transfused her and then removed about one-third of the placenta vaginally with an ovum 
forceps and the hand. The patient recovered. 



278 


AJIERICAN JOURNAIj OP OBSTETRICS AND GYNECOLOGY 


Practically aji identical case occurred in our clinic at tlie Eescarcli Hospital. Tlie 
placenta -was removed successfully with the hand several hours after delivery. The 
uterus was packed and the patient recovered. 

In spite of the fortunate outcome in those eases, I feel, with Dr. Dorsett, that the 
radical treatment is the one of choice if after an attempt at removal it is felt that the 
placenta is too adherent or that it has not been completely removed, or if the patient 
bleeds following the packing of the uterus after it is thought that all of the placcnt.al 
tissue is removed. I tliink we are inclined to be too conservative about removing the 
uterus under these conditions. We are inclined to wait too long and let the patient 
bleed, become anemic and possibly develop a sepsis. Then when we decide that the 
uterus should bo removed, conditions have developed wliich make hysterectomy ex- 
tremely dangerous. 

It is not always easy to differentiate between different degrees of adherence of pla- 
centa accreta. At the Chicago Lying-In Hospital, a resident found that the patient had 
a very adherent placenta, which he could not deliver by tlie usual methods. He inserted 
his hand into the uterus and found a very adherent mass. Finally he loosened it 
and on withdrawing his hand he found to his surprise that he had done a submucous 
myomectomy. 

When placenta accreta is diagnosed or suspected an immediate determination by in- 
trauterine manual exploration is indicated, followed by hysterectomy in all cases where 
insuperable difficulty is encountered in the removal of the placenta and this before 
severe postpartum hemorrhage or sepsis has increased the risk to the patient. 

DR. FOSTER S. KELLOGG, BosTOir, Mass. — I have happened to be associated in 
one way or another with perhaps twelve or thirteen cases that have been diagnosed a^ 
adherent placenta. In my experience, the pathologists’ reports have not been definite 
nor so satisfactory and I would like to raise this question in connection with the sub- 
ject: Speaking broadly, there arc clinically two distinct types of placenta accreta, one 
in which the placenta may bo largely clawed off, and with or without packing the pa- 
tient survives. The remaining pieces slough off, provided curettage is not resorted to, 
in about twenty-one days, or they come away in a puslike lochia and are never recog- 
nized. In the other type the patient may be saved only by hysterectomy. Dr. Mallory 
studying both of these varieties in the pathologic laboratory invariably sends back the 
same rejDort on the one or the other specimen. In other words, translating his pathology 
into our clinical observation, it is purely a qualitative matter. I hope further patho- 
logic study will reveal some quantitative rather than qualitative differences. 

DE. BETHEL SOLOMONS, Dublin, Ireland. — I feel that obstetricians who have 
a large experience make very clear the fact that placenta accreta is an extraordinarily 
rare condition because I find that junior obstetricians seem to think that it is a verj- 
common thing from reading a few cases reported. 

One point that has been made clear is the differentiation between placenta accreta 
and adherent placenta. If a junior tells me that he has an adherent placenta in a 
primipara, I do not believe it. I have never seen such a thing. I have seen placentas 
that have been called adherent and I always find them to be simply retained placentas. 
In the last 50,000 labors at the Rotunda Hospital there has been no ease of placenta 
accreta, so I think it may be taken as a very rare condition, in Ireland at any rate. 
However, I had a patient during the last two months upon whom I operated. It iras 
that of a woman doctor who was having an operation outside the hospital. She was one 
of those patients who, in the absence of anything pathologic had had a dead baby in 
her first confinement. A complete routine examination was made of both the patient 
and the fetus in an effort to find out why the baby had died. She was a woman of 
forty-two and after consultation it was decided to do a cesarean section when she came 
to term. On attempting to remove the placenta it was found that it could not be budged. 
It was welded to the uterine wall and the attempt was given up because obviously it 



dorsett; placenta accreta 


279 


would have been necessary to tear large pieces out of the uterine wall. A hysterectomy 
was performed. It was a true placenta accreta. 

DE. ALBEET MATHIEU, Portland, Oregon.— I have among my case reports one 
of a placenta accreta found at cesarean section and complicated by a breech presen- 
tation, a large cyst of the cervix and a cervical stenosis. Because of a breech presenta- 
tion in a forty-three-year-old primipara with an undemonstrable external cervical os 
and a large cervical cyst, I started a classical cesarean section. A baby weighing 
4285 gm. was extracted. Upon attempting to remove the placenta it was found to be 
growing into the myometrium and attempts to lyipe it loose with a towel were of no 
avail. At each effort masses of placental tissue were left attached to the uterus. As 
considerable blood was being lost during the procedure, a rapid supravaginal hyster- 
ectomy was performed. The pathologic examination showed that the placental sub- 
stance had apparently grown directly into the uterine tissue. A number of fibrous 
infarcts were present about the borders of the placental substance, and they also had 
a very close contact with the uterine wall. Cut sections through the placental sub- 
stances showed it to be apparently normal. 

Section through the placenta and uterine wall showed no distinct line of separation. 
The covering of the placental i-illi was continuous with the connective tissue stroma 
of the uterine musculature. Some of the decidual cells were in the formation of islands 
which were entirely surrounded by uterine muscle. 

DE. JAhlES E. DAVIS, Ann Arbor, ADch. — The pathology of this condition un- 
doubtedly involves changes in blood vessels and blood spaces. The m)’ometrium fails 
to normally limit the advance of the chorionic villi, and there follows a narrowing 
or thinning of the myometrial wall. Two grades of attachment of the placenta and 
myometrium can be described. Grade one can be considered somewhat akiir to a 
diphtheritic type of infection. This type of infection would glue the placenta to the 
uterine wall but it would be possible to peel off the placental tissue, leaving a bleeding 
surface. In the second grade, because the blood supply has been destroyed and be- 
cause the chorionic Will have advanced far into the myometrium, there is no possibility 
of separating the placenta from the myometrium. Here is the genuine type of in- 
separable placenta accreta. 

In the first grade of attachment low grade infection may play a part in the adhesive 
process. 

DE. EAYAIOND A. D. GILLIS, Pittsburgh, Pa. — I should like to report my ex- 
perience -with one case. The patient came to the Alerey Hospital in Pittsburgh with a 
history of having been treated by a large dose of radium five years previously at the 
same institution. After the radium treatment she had not menstruated, so far as the 
history was obtainable. She was admitted to the hospital suffering from considerable 
abdominal pain and uterine discharge for weeks. She presented a mass in the abdomen 
about the size of a four or five months’ pregnancy. There was some fever, the mass 
was tender and there was a foul discharge from the vagina. A diagnosis of pregnancy 
could not be made either by bimanual or abdominal examination and only with x-rays 
could the fetus be showir and its position determined. She had been in labor and hav- 
ing ineffectual contractions for a period of a week. By this time the uterus was in- 
fected and the membranes ruptured. It was possible to move the fetus around so that 
a foot could be brought through the cervix and finally a macerated fetus was delivered. 
Following this the placenta showed no sign of separation from the uterine wall, and 
it was concluded, on account of the previous radium treatments, that she probably 
had considerable atrophy, if not entire absence, of the decidua and possibly had a 
placenta accreta. No attempt was made on this account to remove the placenta from 
below and an immediate hysterectomy was recommended. The patient declined this 
operation and was sent back to the ward. Some days later the placenta was found to 



280 


AMERICAN JOURNAL. OP OBSTETRICS AND GYNECOLOGY 


be intact and, apart from developing a certain amount of cellulitis, tlie condition 
cleared up in a few weeks without any ill elTects. 

DE. ARTHUR J, SKEEL, Cletoland, Ohio. — For the last five years it has been 
our custom not to invade the uterus for a retained placenta. If the placenta is not 
expressed in a couple of hours the patient is put back to bed and not disturbed for 
eighteen to twenty-four hours, and in that time we have never failed to express the 
placenta readily without invading the vagina. I take it from the pathology of the 
placenta accreta that there should be no immediate hemorrhage. I am wondering 
what the indication was for removing the placenta manually and whether in the process 
of our usual procedure of letting the patient go back to bed for twenty-four hours 
if she had a true placenta accreta, would there be risk of lieinorrhage" 

DR. DORSETT (closing). — feel that one of the etiologic factors in placenta ac- 
creta is the fact that a previous dilatation and curettage has been done. I am sure we 
all have reports returned from the laboratory that the tissue contained decidua plus 
uterine muscles ; wliich proves that we have been a little too energetic in our cur curette- 
ments either for retained placental tissue or for diagnostic curettage. 

Dr. Kellogg has brought out an interesting point in regard to the two types of 
placenta accreta and I feel that there is a difference of degree in the penetration of 
the villi. In some cases tliey may only penetrate a very short distance, and in other 
cases which have been reported, the pathologic specimens have shown where they have 
penetrated entirely through the muscularis of the uterus and doivn to the peritoneal 
coat. 


ENDOMETRITIS AND PHYSOMETRA DUB TO WELCH 

BACILLUS* 

Frederick H. Palls, M.D., Chicago, III. 

(From the Bepartvicnt of Ohstctrics and Gynecology, Vniversily of Illinois College 
of Medicine, and Cook County Hospital) 

P uerperal sepsis due to oi* associated witli the Welch bacillus is 
relatively uncommon even in the practice of obstetricians of wide 
experience, and on active ohstetidc services. For this reason the nature 
of the infection, its pathogenesis, methods of diagnosis and management 
are often not thoroughlj^ understood by the medical attendant, and the 
dangers and responsibilities attending such a case may be overlooked. 
In order for these factors to be fully appreciated, it becomes necessary 
to establish in the minds of the clinicians certain fundamental facts that 
have to do with the bacteriology and pathology of this disease so that 
intelligent management 'of a given case may be assured, even though the 
experience of the medical attendant may be limited in the care of this 
disease. 

Most of the reports in the literature have to deal with individual case 
reports or small series of fatal eases. Reports from the surgical field also 
show a high mortality in this type of infection. The sinister reputation 
thus acquired has so stamped this disease that the clinician on realizing 
the presence of a gas bacillus puerperal sepsis is prone to give a very 

♦Read at a meeting of the Chicago Gynecological Society, April 15, 1932. 



FALLS : ENDOjNIETRlTIS AND PHTSOMETRA 


281 


poor prognosis -witliont attempting to base the same on a careful inter- 
pretation of the bacteriologic, patbologie, and clinical facts. 

Because my experience ■witli this disease has been ratlier unusual in 
that none of tbe cases bave proved fatal it occurred to me tbat a presen- 
tation of this phase of the subject might be of service in rounding out 
the picture of gas bacillus infection in your minds. Moreover, I wish 
to point out that often the gas bacillus infection is present in certain 
puerperal cases and totally unsuspected. 

Also, I wish to show that certain clinical phenomena when present 
should lead to a bacteriologic examination of the vaginal tract, the technic 
of A\diich is very simple. Finally to emphasize the importance of me- 
ticulous care in the handling of these cases to avoid injury to the soft parts 
that might serve as a portal of entiy for the infection into the blood stream 
or lymphatics. 

There was considerable confusion in the minds of the earlier workers 
in this field due to the fact that a number of different names were ap- 
plied to the same organism, and also, that the gas bacillus was not ob- 
tained from wounds in pure culture which led to confusion regarding 
its cultural characteristics. It is now recognized that the Vibrion septique 
of Pasteur, Bacillus Perfringens of the French, Fraenkels, Bacillus 
phlegmones Emphysematosae, Bacillus emphysematis vaginae, Linden- 
thal, Granulobacillus saecharobutyricous imobilis liquifaciens of Schat- 
tenfroh and Grassberger, BaciUus aerogenes aerophilis agilis, Uffen- 
heimer, and Bacillus septique aerofie of Legres and Lecene are all the 
same organism as that described by "Welch and Nuttall in 1892. 

The first fact that strikes one on investigating the cause of this infec- 
tion, is that the human intestine and that of all of the domestic animals 
and rodents contain the organism. Immediately one remembers that 
most deliveries are attended by the extrusion of fecal material from the 
rectum late in the second stage of labor. 

Even though the small particles of fecal matter are carefully removed 
as soon as they appear at the anus, bacteriologic contamination of the 
perineum and vagina is easily conceivable. The gas bacillus is probably 
a normal inhabitant of the vagina of women who have had a third degree 
tear or who have rectovaginal fistulae. When one remembers the con- 
tamination of the vaginal tract which probably frequently occurs in 
the most expert hands during a difficult forceps delivery or breech 
extraction, and which must occur almost invariably in the hands of in- 
experienced obstetricians during these operations, it is difficult to see 
yffiy a large percentage of these cases are not exposed at least to the 
infection. It must follow therefore that only under exceptional cir- 
cumstances does the gas bacillus produce infection and acquire the 
invasive power of a true pathogenic organism. 

If this were not true there should occur epidemics of this type of in- 
fection. Furthermore the severe fulminating types of infection as in 



282 AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 

the cases recently described by Toombs should be much more common 
than they are found to be among puerperal se^isis cases at this time. 
There is relatively little mention in the literature of the nonfatal tj^pes 
of gas bacillus infection. 

The reason for this seems to be that the clinicians either do not ap- 
preciate the significance of the presence of gas in the generative track 
or they do not appreciate how relatively simple the bacteriologic technic 
is for the isolation of these bacteria in a given case. 

PATHOLOGY 

According to Welch there arc five groups or types of cases. 

Group I . — In which the fetus or product of conception shows 
einph.vsematous infiltration. These eases may show little or no general 
reaction. 

Group II . — Puerperal endometritis in which the gas bacillus does not 
penetrate the uterine wall and the inflammatory j-eaetion is limited to 
the endometrium. There usually is some general reaction which sub- 
sides in a few daj^s and the patient goes on to recovery. 

Group III . — Physometra or Tympania utei’i in which the uterine 
cavity is distended with gas produced by the Welch bacillus. It has 
been shown that the colon bacillus and other gas producers never form 
large amounts of gas in the tissues of any but diabetic patients. 

Group IV . — Emphysema of the uterine wall is usually associated with 
tjrmpania uteri and is due to invasion of the Avail by the gas bacillus via 
the lymphatics, K. Bingold. These cases are usually fatal. 

Group V . — Gas sepsis in Avhich the bacillus invades the blood stream 
through the blood vessels of Ij’^mphaties produce hemaglobinemia, jaun- 
dice, bronzing of the skin and later anemia. Nearly all of these cases 
are fatal. 

The detection of a gas bacillus infection is as a rule not difficult if one 
is alert for the clinical manifestations of the disease and prepared to 
confirm clinical impression by bacteriologic iiiAmstigation. The clinical 
picture varies from no general symptoms at all on the one liand to seA'-ere 
manifestations of a fulminating fatal puerperal sepsis on the other. 

Since Ave are concerned Avith the milder nonfatal type of infection in 
this paper, Ave Avill confine ourseNes to the symptoms seen in these cases. 

The first thing that may arouse suspicion in the inind of the at- 
tendant regarding the possibility of a gas bacillus infection is the pres- 
ence of gas bubbles in the Amginal secretions of Avomen aborting or 
in actiAm labor. This may be the only symptom or sign until the product 
of conception is passed at which time it Avill be seen to haAm gas bubbles 
on its surface, and in the case of Avell advanced fetuses there may be 
marked emph3''sematous infiltration of the subcutaneous tissues, and 
especially the “foamy Ihmr. ” Wlien the condition is more adA'anced to 
the stage of puerperal endometritis, there are frequently seen septic 



PALLS; ENDOMETRITIS AND PHYSOMETRA 


283 


plienomena such as fever, rapid pulse, leucocytosis, chills and nausea 
and vomiting. The uterus maj’- be noted to be higher than usual, and 
tympanitic to percussion. The fetal outline ■will be masked and the 
uterus may be in tetanic contraction. The whole picture may simulate 
somewhat that seen in premature separation of the placenta except for 
the absence of signs of hemorrhage. Gas may be heard or seen escaping 
from the vagina with a crackling sound and the odor is a peculiar 
sjveetish foul odor which is characteristic and once observed ivill almost 
suffice to establish a diagnosis without further investigation. The amount 
and tension of the gas in the uterus is almost unbelievable in some of these 
eases. This condition is only seen in women with well advanced preg- 
nancj^ Avhere the presenting part effectivelj’ blocks the lower uterine seg- 
ment and cervix. In two of our cases on luishing up on the fetus a rush 
of gas was heard whistling out of the uterus as if a knife had been plunged 
into a tightlj'- inflated football. 

PolloAving delivery in these cases there is usually a febrile reaction 
for a feiv daj’^s and then an uneventful conAmlescenee. On the other 
hand the infection may go on to emphysema of the uterine wall, thrombo- 
phlebitis, lymphangitis, and fatal septicemia. Not all cases in which 
the organism has been cultivated from the blood sboiv serious symptoms. 
According to Bingold one-third of all cases yielding positive blood cul- 
tures run an afebrile clinical course. We must explain this on the as- 
sumption that these organisms are relatively avirulent and ivere 
forced into the blood stream rather than that they gained entrance by'' 
their virulent penetrating power; and further that they y'ielded to 
the bactericidal poAver of the blood or the organs to AAhich they' are 
carried. It is probable that in most cases they' cannot multiply' in the 
blood stream because of its oxy'gen content until just before or just after 
death. 

The bacteriologic diagnosis in a case suspected of harboring the gas 
bacillus is readily and simply' made. Tavo ordinary tubes of litmus milk 
are poured together so that the resultant tube Avill be about half full of 
milk. This is then placed in boiling Avater for a fcAV minutes to drive 
off the oxygen. On cooling a cream ring layer of fat Avill be noticed 
on top of the milk. This milk is then inoculated by means of a sterile 
SAvab or platinum loop dipped in the vaginal secretions ; and incubated 
at 371/2° over night. The next morning the so-called stormy fermenta- 
tion Avill have occurred if the gas bacillus is present. This consists of 
the formation of a large amount of gas in the coagulum of the milk which 
has turned acid in reaction. In some eases the stoppers are bloAvn out 
of the tubes. Liquefaction of the coagulum also takes place. Gas bub- 
bles Avill be seen rising from the bottom of the tube and collected on the 
surface of the media. From the milk, smears are made and rather heavy 
gram-positive rods can be seen. Capsules can be demonstrated by special 
stains. A few cubic centimeters of the culture injected into the ear vein 



284 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


of a rabbit are allowed to circulate for a few minutes and then the rabbit 
is Idlled aud placed in the incubator for twenty-four hours. Autopsy 
shows the rabbit enormouslj'’ distended with gas and what is most charac- 
teristic the so-called “foamy liver.” This appearance is due to numer- 
ous gas bubbles that arise from the fermentation of the glycogen in the 
liver cells. Smears from the rabbit 's tissues reveal the capsulated organ- 
ism. 

The clinical material upon which these observations were based was 
studied at the Cook County Hospital, University of Iowa, and at the 
University of Illinois Research Hospital. The patients were all chai’ity 
patients and all were white women. Two of the series were at or near 
full term and had had labor pains for several hours with ruptured mem- 
branes and prolapsed cord. The other four were abortions in the early 
months. The details of the ease histories are of interest and of some 
importance because of their beaidng on the clinical management. 

Case I. — ^Primipara twenty-two yoara old, Polish, had boon in labor abont fourteen 
hours when admitted to tlie Cook County Hospital about C A.xr. one morning. She 
had been attended at her home by a midAvife Avho made repeated vaginal examina- 
tions and who, when the membranes ruptured and the cord prolapsed, called in two 
doctors. They in turn tried to replace the cord and deliver the woman by version 
Avithout success. The patient Avas then told that she would have to go to the 
County Hospital for delivery. She got up and dressed, and Avith the cord hanging 
doAvn to her knees, boarded a street car and came about eight miles across toAvn 
to the hospital. On admission the patient was prepared obstetrically. The pulse- 
less discolored cord Avas disinfected as carefully ns possible and cut off at the vulva. 
On vaginal examination the cervix Avas found to be about four centimeters dilated, 
pains rather weak and coming about every fiA’e minutes. A Voorhees number five bag 
was inserted and weight attached. This started good pains and the bag was ex- 
pelled about 5 F.M. at which time nearly complete dilatation was present. On 
examination a hand and arm were found prolapsed in the vagina. 

A sweetish foul odor was noticed but not correctly interpreted. Gas bubbles were 
noted in the vagina but still the diagnosis was unsuspected. It was decided to try 
carefully a podalic version to determine how tightly the uterus was clamped dovrn 
on the child. On pushing up on the -shoulder a large quantity of gas escaped with 
a whistling sound audible all over the room and filling the latter Avith the character- 
istic sweetish foul odor. I then made a tentative diagnosis of Welch bacillus in- 
fection and at the same time decided that A'crsion was too dangerous to attempt. 
The only alternative was decapitation, the prospect of which was anjdhing but in- 
viting because I realized fully the consequences of injury to the maternal soft parts, 
and implantation of gas bacilli into woimded smooth muscle. However, by careful 
manipulation of the Braun blunt hook over the neck and using a heavy blunt clei- 
dotomy scissors to cut through the soft parts, I was able to decapitate and remove the 
fetus which was emphysematous throughout and from whose tissues the W elch bacillus 
was recovered in smear and culture. The next morning her temperature was 105.4 
and she was tender over the loAver abdomen and showed all tlie signs of a severe 
puerperal sepsis. My prognosis in the light of what I had read regarding gas 
bacillus infection was absolutely bad. I was greatly surprised to find her slightly 
improved the next day and temperature free on the sixth day. She left the hospital 
on the fourteenth day Avith no sign of residual pathology. 



FALLS: ENDOMETRITIS AND PHYSOIMETKA 


285 


Case 2. — Para iii, 'wlio, -when first seen by me, was completing a three months’ 
abortion. She was on. the delivery bed at the Cook County Hospital, and there was 
no thought of infection in connection with the case in the minds of the attendants. 

The history revealed that the abortion had been self induced by inserting into the 
cervix a piece of slippery ehn which the patient had carried around in her pocket- 
book for two years. This had been done about twenty-four hours before and had 
resulted in some hemorrhage and the onset of uterine cramps. The patient had no 
fever and no evidence of septic reaction. On making suprapubic pressure to see 
whether the product of conception could be expressed, gas bubbles were noted com- 
ing from the vagina along ivith a small amount of bloody secretion. Culture taken 
in litmus milk showed stormy fermentation and gave the characteristic findings 
when injected into a rabbit. 

The clinical course was absolutely symptom free as regards temperature, pulse, 
pain, and tenderness, and she left the hospital on the eighth day. 

Case 3. — ^Almost a duplicate of Case 2 except for a slight fever 100.4° and 
leucocytosis. Attention was called to the possibility of a gas bacillus being present 
by the gas bubbles present in the fetus and placenta after expulsion. The abortion 
was spontaneous at the fourth month and no definite history of interference was 
obtained from the patient. The temperature came down to normal the next day 
after the abortion. 

Case 4. — Twenty-two-year-old primipara, three months pregnant, entered the 
clinic of the University of Iowa with a temperature of 102.4°, pulse 120. She was 
having severe cramps and was flowing slightly. According to her history, a doctor 
had induced the abortion by introducing a stick of slippery elm into the cervix 
four days before. Issuing from the vagina was a bloody discharge which contained 
gas bubbles, and which gave the characteristic sweetish foul odor. The whole fetus 
was blown up with gas when extracted. Gram stain of the fetal tissues showed a 
gram-positive organism and cultures and animal inoculations showed the typical 
Welch bacillus. The day before entry to the hospital, she had several severe chills 
and fever. On examination the whole abdomen was rigid and there was marked 
tenderness in both lower quadrants extending to McBurney’s point on the right. 
There was a tender firm mass in the midline of the abdomen extending to within 
two fingerbreadths of the umbilicus taken to be the uterus. No fetal movements 
or heart tones could be elicited. On rectal examination the slippery elm stick 
could be felt in the cervix, and on pulling on a string protruding from the 
vagina the stick came out of the cervix. It was about three inches long and a 
fourth of an inch in diameter. 

The patient was transferred to the contagious hospital. Her temperature came 
down to normal on the fourth day and she made an uneventful recovery. 

Case 5. — ^Thirty-seven-year-old para ix, pregnant two months, who entered the 
clinic of the University of Illinois because of a severe heart lesion. The heart was 
partly decompensated. She was admitted July 2 and was treated for her cardiac 
decompensation until July 30 when she went into labor spontaneously and aborted in 
about one hour. There was no history of vaginal examination before she started 
to abort, and she was in the hospital under observation for twenty-eight days before 
tlie abortion started. The possibility that she examined herself vaginally is to be 
considered. When the fetus was expelled it was found to be emphysematous. This 
led to culture and smears and animal inoculation which revealed the gas bacillus. 
She had no temperature previous to or following this abortion and left the hospital 
the tenth day with no evidence of residual pathology. 

Case 6.— Para i, thirty-three years old, entered the ward September 30, 1931, 
at 12:15 A.M., with the history that the membranes had ruptured prematurely and 



2S6 AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 

that the cord had prolapsed immediately. The cord was not pulsating but the resi- 
dent attempted unsuccessfully to replace it in the uterus. The baby was in trans- 
rerso presentation and an arcuate typo of bicormiatc uterus was diagnosed. An 
attempt was made to sustitute a breech for the transverse presentation. Pains started 
about 8 P.M., twenty hours after admission and became strong the next morning. 
The cerri.v dilated slowlj' and at 1 p.m. an arm prolapsed.. On examining the pa- 
tient, I found the uterus to be ballooned up and very tense. The pains were strong 
and tetanic in character. There were some bubbles of gas escaping from the vagina 
on rectal e.xamination. The temperature was 101.8° and the pulse 144. A diag- 
nosis of physometra and gas bacillus infection was made and under deep ether anes- 
thesia version gently attempted. On pushing up the shoulder explosive expulsion of 
a gi’cat quantity of sweetish foul swelling gas occurred. Because version could 
not easily be accomplished and because of our success with Case 1, it was decided to 
do a decapitation following the same technic. This was accomplished without ap- 
parent injur 3 ’ to the uterus or vagin.a and the baby slowl 3 ' and gentlj' delivered. 
Tj'pical emphj’sema of the tissues of the babj" was revealed. The temperature drop- 
ped to 100.4“ the next daj’ and to normal on the tliird daj'. She left the hospital 
on October 11 with no evidence of residual infection. The gas bacillus was proved 
bj’ smears, cultures, and animal inoculation. 

All analysis of these cases would seem to show that the gas bacillus 
may be present in certain cases without giving any striking clinical evi- 
dence of its presence. This it seems to me is an important point from 
the standiioint of unsuspected contamination of our birth rooms and 
maternity wards. It would seem, however, that there is little danger of 
starting an epidemic of this type of puerperal sepsis as there seems to be 
no mention of such in the literature. 

The first, fourth, fifth, and sixth ca.ses are examples of phj'sometra and 
the infection was apparentlj’’ limited to the fetus and the endometrium. 
This was evidenced clinically by the failure to develop the hemoglo- 
binuria, liemogiobinemia, and the bronzing of the skin. Unfortunately 
blood cultures were not made in any of these eases, but according to 
Bingold they are positive in one-third of such cases. A positive or nega- 
tive culture would have had little clinical significance. A complete bac- 
teriologic study of the secretions for mixed infection also Avas not made 
except that the smeai’s from the fetal tissues, milk cultures, and animal 
inoculations showed an overAvhelming preponderance of the Welch 
bacillus. This Avork confirms the experience of Schottmuller, Bingold, 
Briitt and others of the preponderance of the cases in infected abortions 
and in patients Avith prolapsed coi’d especially Avhere operative interven- 
tion has complicated the labor. It would also seem to confirm the opin- 
ion of Welch and others that the organisms are largely saprophytic un- 
less they are implanted upon dcAutalized tissues, and it may be that sec- 
ondaiy invaders such as the Streptococcus putridis or colon bacillus are 
necessary to enhance their virulence. 

I feel that it should also be pointed out in this connection that in spite 
of the fact that it has been shown that the organism can produce inflam- 
matory changes it has not as yet been shown that it fulfills Koch's laAvs 



falls: endometritis and physometba 


287 


with respect to the disease. Furthermore its lack of pathogenicity for 
lower animals is shown by the fact that it is necessary to kill the inocu- 
lated rabbits in order to get the organism to grow and produce the char- 
acteristic tissue changes. Practically all of the fatal cases reported in 
which careful bacteriologic examination was carried out showed a mixed 
infection often with a streptococcus concerning whose Yirulence there is 
no reasonable doubt. 

Our treatment of these cases was the routine for anj’^ infected puer- 
peral case. The head of the bed Avas elevated, fluids pushed, and one 
dram of fluid extract of ergot Avas given four times a day for three days. 
Serum Avas not aA^ailable for the first fiA'e eases and Avas not giA^en in the 
last case because the clinical course Avas so benign at the time when the 
serum Avas obtained. 


Table I. Eesults op Vaginal Cultures 


SOURCE 

POSITIVE 

NEGATIVE 

TOTAIi 

PERCENT 

POSITIVE 

Uesearcli and Educational Hospital: 





Prenatal Dispensary 

7 

138 

145 

4.82 

Gynecological Dispensary 

5 

10 

15 

33 

Cool: County Hospital; 





Incomplete Abortions 

5 


22 

29.41 

Prenatal Dispensary 

8 


112 

7.69 

Gynecological Hospital Cases 

8 


76 

11.76 

St. Vincent’s Hospital; 





Prenatal Dispensary 

0 

13 

13 

0 

Totals 

33 

3.50 

383 

8.61 


In order to determine something of the frequency of the gas bacillus 
in the vagina of prenatal, puerperal, postabortal, and gynecologic cases, 
a survey was made at the Cook County, Research Hospital and St. 
Vincent’s Home. Gram stain and the reaction in litmus milk Avere used 
to denote the presence of the gas bacillus. A feAv of the cultures found 
to be positive by these tests Avere run through rabbits. The results shoAvn 
in Table I, indicate that the gas bacillus is present in prenatal cases in the 
smallest number, next in gynecologic cases and most frequently in the in- 
fected abortions. This corresponds well Avith the work of Mouchette Avho 
found the bacillus perfringens in 13 out of 18 cases of abortions between 
the second and fifth month. 

Jeannin found 12 positive cultures out of 18 similar eases and 2 of these patients 
died. In 1 patient there was no fever, in 3 the temperature dropped from 104° 
to normal as soon as the uterus was emptied, while 2 had a sudden drop to normal 
after a preliminary rise. He had 3 cases of physometra, 2 patients died 



















288 AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 

Eist and Moucliette report 3 cases of infected abortion witb verj* high tempera- 
ture, but with eventual recoverj-. 

Little reports 9 cases of 'Welch bacillus infection of the uterus which oc- 
curred at Jolins Hopkins Hospital, 2 of which were previousl}’ reported by Dobbin. 
Seven of the 9 patients recovered and in most of the details were comparable with 
my cases. He states however, that no one had cultivated the gas bacillus from the 
normal vagina up to 1905. 

CONCLUSIONS 

1. The gas bacillus of Welch is relatively common in septic abortions. 

2. Gas bubbles in the vagina of ivomen aborting or in labor should 
lead to an investigation for the gas bacillus. 

3. Its detection and isolation requires onlj' a veiy simple bacteriologic 
technic. 

4. When diagnosed, these infections should be handled with the great- 
est care to avoid wounding the soft parts. 

5. Such eases should be handled with strict isolation technic durmg 
their stay in the hospital. 


REFERENCES 

(1) Toomlis, P. TV.: Tr. Am. Assn. Obst. & Gynec. & Abd. Surg. 40: 99, 1927. 
(2) TVelcli: Johns Hopkins Hosp. Bull. 11; 185, 1900. (3) Bingold: Virchow's 
Arch. f. path. Anat. 24G; 17, 1923. (4) ScltoUmtiUcr : Munchen. mod. IVchnschr. No. 

11, 15, 1911. (5) Kcyncmann : Ztschr. f. Geburtsh. u. GjuiUk. No. 68, 11, 1911. (6) 

Sniff; Zentralbl. f. Gyniik. No. 33, 1317, 1923. (7) Wdcli: Jolms Hopkins Hosp, 

Bull. 11; 185, 1900. (8) Movcheite: Documents pour sorvi a I’etudo do I'liysterec- 

tomie dans 1 'infection puerperal post abortein, These de Paris, 1903. (9) Jeannin: 

Etiologie et Pathogenie des infections puerpcralcs putrides, These de Paris, 190-.. 
<10) hist and Moucliette: Compt. rend. Soc. de biol. 54: 363, 1902. (11) Little, 

Hericrt M.: Johns Hopkins Hosp. Bull. No. 169, 136, 1905. 

1819 "West Polk Street. 


PUERPERAL SEPSIS: B. WELCHII, FATAL TYPES* 

A. P. Lash, Ph.D., M.D., Chicago, III. 

(From the Department of OhsteMcs and Gynecology, University of Illinois, 
College of Medicine and the Cool; County Hospital) 

T hat type of puei'peral sepsis due to the Bacillus Welchii, (Bacillus 
perfringens, Bacillus aerogenes capsulatus or PranlvcPs bacillus), 
which is usually fatal, is uncommon. When it does occur, the im- 
portance of making an early diagnosis and to determine the clinical 
type in order to intelligentty treat the condition, warrants furtlier 
emphasis and repetition of its ehai-acteristic clinical- conrse. Anotlier 
reason for presenting this paper is the interesting blood chemistry and 
renal changes observed in two patients who died as a result of this 
infection, one early and one late. 

Wrigley, having observed six fatal cases of puerperal sepsis due to Bacillus 
■Welchii out of a total of sixteen puerperal sepsis deaths from 1922 to 192; at the 


*Reacl at a meeting- oE the Chicago Gynecological Society, April 15, 19o2, 



LiASH: PU33RPERAIJ SEPSIS 


289 


St. Tliomas Hospital, London, was stimulated to study tlie incidence of these 
organisms in normal and pathologic pregnancies, labors, and pucrperiiims. He 
reported his results in 1930, which were as follows: In 50 women cultured at 
the beginning of labor, no Bacillus Welchii was isolated. In 100 women with 
normal pregnancy, labor, and puerperium no Bacillus Welchii was found in the 
lochia. Therefore, from the literature he reviewed and from his investigations 
he concluded that Bacillus Welchii 'was not present in the cervix before or in 
the lochia following delivery, in cases in which the pregnancy, labor, and puer- 
perium were normal. However, Schottmullcr claims that it may be occasionally 
found in the vagina of normal, healthy women and that autoinfection is possible. 

Wrigley also studied 69 women with abnormal pregnancies, labors, or puer- 
periums. In this series he was able to isolate the Bacillus Welchii from the 
lochia of 13 patients. Four of these developed a generalized gas bacillus infec- 
tion. Yet in 16 patients, in whom violent efforts to deliver the child were made, 
there were no uterine infections with pathogenic anaerobic organisms. There- 
fore, he concluded that certain conditions- must be present for severe maternal 
infection to occur, such as; The organisms must be introduced into the uterus; 
the organisms must find there suitable material, namely, dead tissue on which 
to grow; the infected tissue or fetus must remain in the uterus for a sufficient 
length of time; and finally, the damaged maternal tissues must be exposed to 
the infection provided in this manner. 

Lehmann and Hraenhel reported in 1924 that they found the gas bacillus in 
106 cervical cultures of 580 abortions. There was no further propagation of 
these organisms since no clinical evidence of infection occiirred. In IS gas bacil- 
lus bacteremias, the organisms were found in the blood in 14 instances following 
curettage, in 2 instances after chills, and in 2 after a rise in temperature. 

In a series of 41 puerperal septicemias due to the Bacillus Welchii collected 
from the literature, Toombs and Michelson made the following bacteriologic ob- 
servations: The organism was found in the uterus in 19 of the 41 patients. It 
occurred alone in 9 eases, with Staphylococcus aureus in 3, with Staphylococcus 
albus in 1, with streptococcus in 1, with Streptococcus pyogenes in 5, with 
anaerobic streptococcus in 1, and with Bacillus coli in 5. From the blood B. 
Welchii was isolated in 16 cases being associated in single instances with typhoid 
bacillus, anaerobic streptococcus, staphylococcus, pneumococcus, and Bacillus coli. 

Although Toombs and Michelson collected 190 cases, they selected only 41 cases 
of puerperal septicemia (Bacillus Welchii), for analysis. Hrom this clinical data 
they contributed the following facts: 61 per cent of the total number of cases 
were abortions; the nonabortion group (39 per cent) had many causes for pro- 
longed labor which were active in the first stage in 95 per cent of the cases. The 
obstetric conditions producing the prolonged first stage also required frequent 
vaginal examinations and operative procedures. These factors well explained the 
exogenous source of the bacteria and the favorable conditions for their growth 
induced by the intrauterine and vaginal manipulations. Therefore, these statis- 
tics bear out Wrigley in his conclusions. 

The pathology produced by the organism in the puerperal uterus were 
emphysema of the fetus, puerperal endometritis, physometra, emphysema 
of the uterine wall and gas bacillus septicemia. If the process remained 
localized to the ovum or the endometrium and was Avell Availed off, the 
symptoms were slight and the patient usually recovered even though 
the organism was found in the blood stream. Serious consequences fol- 
lowed the entrance of the organism into the uterine musculature. Here 
it grew in the Ijnnph spaces betAveen the muscles and in the lymph spaces 



290 ajikkicak journal, of obstetrics and gynecology 

of the vessels because of their poor content of oxygen. Necrosis of the 
tissues ill their neighborhood resulted. Around these areas of necrosis, 
there ivas a peripheral edematous zone due to the extravasation of the 
blood from the necrotic vessels and its subsequent hemolysis by the 
hemotoxiu. Polymorphonuclear leucocytes were repulsed by a leiico- 
cidin liberated by the Bacillus AVelchii. Through the lymph stream 
the organisms were discharged to give rise to the picture of gas bacillus 
septicemia. The bacteria did not multiply in the blood because of its 
oxygen content but might do so just before death when the oxygen 
eontent was greatly diminished as the circulation was failing. Lehmann 
laid much stress on the renal changes as a cause of death. He believed 
that the kidnej’ obstruction due to the end-products of the broken-down 
hemoglobin was a factor. However, Fracnkel believed that the gradual 
cessation of urinary secretion might be a contributing cause. This 
mechanism was first described by Cohnlieim in 1880. He further stated 
that gas bacillus infection could occur only in organs or structures hav- 
ing smooth or striated muscle elements and that when gas was found 
elsewhere it was usually carried there by the blood vessels. 

The clinical course of the severe or metritic tjq^e of Bacillus Welchii 
infection begins with early characteristic spnptoms. In the 41 puer- 
peral septicemias, the prodromal period was found to occur within forty- 
eight houi’s of the inoculation in 70 per cent of all eases and within 
twenty-four hours in practically 50 per cent. The chief sjnnptoms 
observed in these patients were pain in the lower abdomen, especially 
in the abortive group, vomiting, diarrhea, jaundice, or bronzing of the 
skin with cyanosis, dyspnea with even air embolism symptoms. The 
jaundice and cyanosis were present in a large percentage of the patients, 
as early as twenty-four hours after the onset and as late as the eighth 
day. Emphysema of the skin occurred in only 16.59 per cent of the 
cases and in only 4.74 per cent of these the emphysema was generalized. 

The characteristic observations Avere; fcA^er, usually high, accelerated 
pulse, rapid respirations, tenderness OA’er the uterus, and bloody A'^aginal 
discharge AA'hich Avas foul in some cases. The urine aaus usually scanty, 
broAvnish red Avith much debris. Complete examination of the urine 
disclosed albumin, hyaline and blood casts, methemoglobin, oxyhema- 
globiu, hematoporphyrin, and hematin. The blood picture shoAved a 
marked decrease in the red blood cells and hemoglobin, AAuth an increase 
in the Avhite blood cells. Lehmann and Fraenkel observed that the red 
blood ceUs dropped from 4,200,000 to 2,100,000 and the hemoglobin from 
70 per cent to 30 per cent in the course of six hours. The blood serum 
had a cherry red color and methemoglobin, oxyhemoglobin, and hematin 
were demonstrable. 

Heim emphasized the presence in the blood of pathologic bone marrow cells which 
he claimed could be obserA-ed only in pernicious anemia and gas bacillus sepsis. 
This association of these two diseases has given rise to experimental studies as those 



LASH: PUKBPBBAL SEPSIS 


291 


ot B. S. Cornell nnd Baraelv and Draper, to determme tlie possible cause o£ per- 
nicions anemia in tbe form of a elironie intestinal gas bacillus infection. 

Altliottgli Fraenkel maintained that the hemolysis of the red blood 
cells producing the jaundice was due to the absorption of the toxic 
products from tbe necrotic tissues, Ford and Lawrence sbowed that tbe 
bemotosin liberated by tbe Bacillus Welebii ivas the cause of this 
hemolj^sis. Their contentions were suppoided by the work of others 
(Cornell, Baraeh and Draper). 

The diagnosis could, therefore, be made early on the basis of tbe 
bistory (abnormal labor oy abortion), characteristic symptoms and 
.signs. Toombs stated that jaundice which appeared early and pro- 
gressed rapidly, occiu’red only in the puerperal infection caused hy 
the Bacillus Welehii. The writer has seen several patients with severe 
hemolytic streptococcus septicemia pi'eseiit a similar appearance, HoTiV- 
ever, the other characteristic (urinaiy and blood) changes ivere absent. 
The lack of these hematologic and urinary observations wmuld also dif- 
ferentiate drug intoxication, acute yellow^ atrophy and blood dyscrasias 
from a gas bacillus infection. 

The case histories of the patients observed by me are briefly as f oIIoays : 

Case 1.— V. W,, a white woman, aged twenty years, entered tbe Cook County Hos- 
pital, December 24, 1926, because of sudden profuse vaginal bleeding which began 
that morning after some housework, and continued at intervals tlirough the day. 
She considered herself about six weeks pregnant. She denied that any attempts to 
abort her were made. Physical examination revealed a young woman, not appearing 
acutely ill, with a bluish, coppery colored skin, temperature 101° P., pulse 128, and 
respiration 36. The essential observations were tenderness over the lower abdomen 
and vaginal bleeding. The eervi.v was soft, dilated one centimeter; the corpus some- 
what enlarged, up and free; the adnexa were free. The urine was black, foul, con- 
tained much debris, and gave a strongly positive reaction for albumin. The same ob- 
servations were present on repeated examinations. The blood picture was B.E.G., 
1,050,000; W.B.C., 16,600; hemoglobin 40 per cent. The ^YasseTmann reaction rvas 
negative. The blood chemistry determinations were: 



UREA N. 

UREA 

CREATININE 

December 26 

97.00 

207.58 

5.00 

January 3 

200.00 

428.00 

24.00 

January 7 

305.00 


14.32 

January 8 

238.00 


20.00 

January 21 

98,00 

208.00 

5.00 

January 22 

206.00 


6.79 

Bacteriologie study of the uterine secretions and 
Blood culture was sterile. 

urine revealed Bacillus Weleliii. 


The patient remained fairly comfortable, the color of the skin becoming lighter 
The temperature varied from 97° P. to 102.6° P. for four days and then became 
normal. The patient vomited once daily and urinated only a small amount each dav. 
Although recovering from the infection, she became weaker and on the thirtieth day 
in the hospital she became restless, irrational and then passed into a comatose con- 
aition and died. 

No autopsy was permitted but with the aid of the pathologist and undertaker, a 
kidney was obtained for study. Microscopic examination of sections stained with 



292 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 



Fig. 1. — Photomicrograph of liver, Case 2, illustrating the Bacillus Yfelchil in the 
necrotic liver cells at the edge of a gas bubble. Death seventy-two hours after 
onset of Infection. X450. 



Fig. 2. — Photomicrograph of kidney. Case 2, illustrating the necrotic coin'oluted 
tubules, the hemoglobin masses in the tubules and the normal glomerulus. 




lash: puerperal sepsis 


293 



Fig. 3. — Pl\otomicrograpli oE kidney, Case 2, illustrating the liemoglobin masses 
in the collecting tubules. xlSO. 



P>'Otommrograph of kidney. Case 1, illustrating the regeneratini 
of 'infection, 'x 370.^" epithelium. Deatli one month after 


con- 

onset 


I 



294 


AJIERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGV 


hematoxyliii auci cosiu show no morphologic change in tlie kidney as the tubules had 
regenerated, but a suppurative pyelitis was demonstrated. 

Case 2.--T. H., a white woman, aged forty, gravida viii, entered the Cook County 
Hospital, March 2, 1931, because of pain in the lower abdomen for two days, vaginal 
bleeding, chills and fever for one day. Having missed her last menstrual period, she 
attempted to abort herself with a catheter on Afarch 1, 1931. Physical examination 
revealed an acutely ill middle aged woman whose skin was a dark copper color and 
whose temperature was 103° P., pulse 120 and respiration 24. The mucous mem- 
branes were cyanotic. Tlio essential observations were, marked tenderness in the 
lower half of the abdomen, soft, patent cervix, and slightly enlarged corpus, A soft 
mass was felt in the ccrvi.x and under sterile precautions it was removed. 

The urine was dark broum and gave a 4-plus reaction for albumin and micro- 
scopically showed many white and red blood cells, debris but no casts. The blood 
count on March 3 was; hemoglobin 70 per cent; R.B.C. 3,350,000 and W.B.C. 
42,250. On Alarch 4 the E.B.C. sank to 1,750,000. Blood smears showed 92 per 
cent neutrophiles, a shift to the loft of over 40 per cent with vacuolization of the 
poljTnorphonuclear leucocj'tes and monocytes. Vacuolization was not confined to the 
older cells but appeared in the mctam)’elocytcs. 

Spectroscopic c.xamiuation of the urine showed neutral methemoglobin and oxj'- 
henioglobiu. Blood plasma showed oxyhemoglobin. 

The cervical culture yielded E. coli, hemolytic streptococci, and B. ‘Welchii. The 
placental tissue showed the same bacteria on culture. Blood culture yielded only 
B. Welchii. A rabbit was injected with the cervical culture, killed and then incu- 
bated. A generalized emphysema developed together with a characteristic foamy 
liver. The blood chemistry showed a nonprotein nitrogen of 80. The clinical course 
of this patient was characterized by high fever, rapid pulse, marked respiratory diffi- 
culty, and anuria until death, forty-eight hours after admission. 

The necropsy was performed by Dr. R. H. Jafte who found essentially: suppura- 
tive endometritis and right salpingitis; diffuse fibrinopurulent peritonitis; septic 
tumor of the spleen; cloudy swelling, icteric discoloration and gas formation of 
liver; cloudy swelling and bloody discoloration of the kidneys; gas formation in the 
myocardium, emphj'sema of the lungs; parenchymatous hemorrhages; gas bubbles in 
the subcutaneous tissue. 

Case 3. — I. AI., a white woman, aged twenty-one years, gravida iii, entered the 
Cook County Hospital, Alarch 19, 1932, in an extremely toxic condition, being irra- 
tional and disoriented. Her history as obtained at a later date was briefly as follows: 
On March 15, 1932, she inserted a slippery elm stick because she had not men- 
struated since January 5. A''aginal bleeding began two days later (Alarch 17). 
Lumbar and abdominal pains associated with nausea and vomiting occurred on 
Alarch 18. Cliills and fever -was experienced and the bronzing of the skin began on 
Alarch 19. Physical examination revealed an extremely jaundiced young woman 
with cyanosis of the nose, finger and toe tips. The temperature was 104.4° P., pulse 
120, respiration 24, and blood pressure 128/74. The tongue was dry and coated. 
Eye ground examination showed a marked cyanosis of the retina. The cheat ex- 
amination revealed no pathology. The abdomen was flat, firm, and elastic with 
tenderness over the low'er part. A^aginal examination found the cervix soft, patent, 
down and back; tbe corpus was enlarged to the size of a six to eight weeks’ preg- 
nancy, tender, soft upright and free; the adnexa were not palpable or tender; 
speculum examination revealed the patent cervix from which extided dark blood. 
Smears were made of this cervical secretion and the gram-positive rods of Bacillus 
Welchii were seen. The urine and blood were immediately examined aud the typical 
cherry red serum and urine were observed. 

The diagnosis was made of: Puerperal sepsis, acute metritis, septicemia. Bacillus 

Welchii. 



LASH: PUBEPEEAL SEPSIS 


295 


Treatment was then immediately started- Complete laboratory results were: 
Cervical enltnre revealed Bacillus Welehii, Staphylococcus albus, and an indifferent 
streptococcus; blood cultures taken at different times were sterile. 


Urinalysk ; 

Color 

3-19-32 Red wine 


Acetone 4-plus Blood 4-plus 

Much debris 


3-20-32 Red wine 20 c.c. in 

24 hours 

3- 30-32 Straw 340 c.c. 1.010 Albumin 4-plus Blood 2-plUB 

4- 3-32 Straw 2140 c.c. 1.010 Albumin 2 -plus Blood 0 

4- 9-32 Straw 1700 c.c. 1.010 Albumin 1-plus 

Blood Bxaminaiion: 

Hemoglobin 

3-19-32 65% 

3-20-32 70% 

3- 30-32 70% 

4- 3-32 50% 

4- 9-32 55% 

Blood Chemistry: 



Urea N. 

Creatinine 

Sugar 

CO, 

Lactic Acid 

Chlorides 

3-19-32 

38.29 

2.25 

64 




3-20-32 

86.38 

9.2 

106 




3-30-32 

214.00 

17.14 

150 

74 



4- 4-32 

168.12 

21.4 


30 



4- 9-32 

82 

3.5 

115 

52 







36 

26.0 

480.0 

The above 

results were 

only the essential ones 

given 

to demonstrate 

the great 


changes occurring. A detail laboratory study will be given in a later report. 

The treatment consisted of; intravenous serum (polyvalent antigas gangrene 
serum) therapy, normal saline, 20 per cent glucose and buffer solution intravenous 
infusion. A detail report of this therapy will be given at a later date. 

The clinical course in this patient gradually changed from a semicomatose uremic 
state to a normal, bright active state so that the patient appears clinically well. 

The prognosis of puerperal sepsis, Bacillus Welehii is dependent on 
the extent of and duration of the infection, the associated bacteria, the 
early treatment wdth specific serum and the degree of kidney damage. 
From the literature it is quite evident that only that type in which the 
uterine musculature was invaded was serious and proved fatal fre- 
quently. One-third of the patients died within forty-eight hours after 
the infection had taken place and over one-half within four days. My 
first patient, V. W., was the only patient to have lived so long after the 
infection. Of course, she recovered from the infection but died from the 
inability to cope with the conditions present with her damaged kidneys. 
The outcome was usually fatal when other organisms, especially the 
hemolytic streptococcus, was also present. In my second patient, T. H., 
tliere was an associated peritonitis due to the other organisms. Accord- 
ing to Briitt and Lehmann, the mortality might be reduced by early 
recognition of the disease and extirpation of the uterus. The additional 
use of the specific serum might he of further value. 


R. B. 0. 

W. B. C. 

Polymorphonuclears 

5,200,000 

46,300 

83% 

4,910,000 

35,600 


3,250,000 

13,400 


3,110,000 

11,600 


3,010,000 

8,950 




296 AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 

The treatment of this type of puerperal sepsis should have for its aims 
the early administration of specific serum and blood transfusion, to over- 
come the marked toxemia, and to prevent the extreme blood changes and 
renal damage ; the gentle encouragement and stimulation of renal func- 
tion by inducing diuresis with normal saline and concentrated glucose in- 
fusions. Such radical procedures as hysterectomj’' which has been used 
by some with apparent success should only he considered Avhen the pa- 
tient’s condition may allow it and when necessaiy. Although it would be 
difficult to set forth rules for hysterectomy, it might be indicated when 
the appearance of the patient and the findings did not change in spite of 
liberal administration of the antigas bacillus serum and blood trans- 
fusion indicating a soiu'cc of great toxin producer (infected uterus) and 
also in the absence of a streptococcal peritonitis. Lehmann used as an 
indication for hysterectomy, crepitation of the uterus on palpation. 
Other recent reports (after 1928) of gas bacillus infections are those of 
Kohl, Baize and Majmr, Ivens and Offergeld. 

COMMENTS 

The mechanism of infection with the Bacillus Welchii has been studied 
in animals b}' DeKruif and Bollman. The primary conditions for in- 
fection are established by the various factors described by Wrigley. 
“The spores introduced at this time are able to germinate, and having 
passed into the vegetative stage, find in the injured muscular tissue, an 
admirable medium for the production of the specific toxic substance. 
This substance, Avith its diffusibility aided by the outpouring of edema 
fluid that invariably accompanies infection, is able rapidly to necrose 
fui'ther tissue and so furnish new medium for the groAvth of the organ- 
isms. Finally an area of necrotic tissue sufficient to furnish medium for 
the groAvth of an enormous number of organisms is produced. These 
then are able to produce enough toxin to bring about toxemic death.” 
(DeKruif, et al.). These investigators do not enter into the discussion 
of the cause of death although the patient has recovered from the toxemia 
and infection. The same method of extension of the infection occurs 
in the human body as observed in autopsi' studies. There is the addi- 
tional factor of associated bacteria that comes into play in human 
infections. 

DeKruif, Adams and Ireland have demonstrated also, that different 
strains of Bacillus Welchii produce toxins of Amrjdng degrees of potency. 
HoAvever, they also shoAved that an antitoxin produced bj^ one strain, 
Avas capable of neutralizing the toxins of other strains. This fact is of 
Amine therapeutically, because a stock antitoxin may be used in the 
presence of an infection of any strain of Bacillus Welchii. Wens re- 
ported a faA'orable report Avitli the serum. 

Although the jaundice and even bronzing of the skin does not occur in 
surgical Bacillus Welchii infections as frequently as in uterine infec- 



LASH: PUERPERAL SEPSIS 


297 


tions, it does occur. Bingold reported a case presenting tlie bronze skin, 
oxybemoglobinemia and metbemoglobinuria, etc., after an infection of 
the tbigli by a bypodermie needle. 

The mai'ked renal changes and the anuria must be elucidated since, 
■with the exception of Lehmann and Fraenkel’s paper, no previous pub- 
lication made mention of them. Mj experience has been especially 
unique in that an early and late kidney -was observed and one apparently 
recovering -with similar clinical pictures. In the early case (seventy-t-wo 
hours after induction of infection) the tjqiical picture of an acute 
necrosis of the proximal convoluted tubules associated with obstruction 
of the tubules with broken-do-wn hemoglobin and cell debris may well 
explain the anuria. These changes were due to the severe toxemia pro- 
duced by the Bacillus Welchii toxin and were the same as in all the tis- 
sues, especially the liver and heart Avhere the organisms also flourished. 
In the kidney of the late ease (one month after the onset of infection), 
the tubules had apparently regenerated anatomically bnt not sufficiently 
pliysiologicalls’’ low sjnieytial character of epithelium of convoluted 
tubules and, therefore, uremia was the cause of death. 

In the patient who has recovered from the infection and is apparently 
recovering from the effects of tlie toxemia, presents some verj’- interesting 
clinical evidence of renal damage and recovery. The effect of the glu- 
cose and buffer solution to produce diuresis is quite evident. The im- 
portance of this diuresis is appreciated when one compares it with the 
diuretic influence of intravenous fluid therapy in the kidnej’’ of mer- 
cury bichloride poisoning. Hayman and Priestly report a case of mer- 
curic chloride poisoning whose anuria was not effected by decapsulation 
of tlie kidneys. Normal saline infusions given intravenously induced an 
increased urinary output and a drop in blood urea nitrogen from 247 mg. 
per 100 c.c. to 85 mg. per 100 c.c. in three Aveeks. The remarkable ob- 
servation Avas that there Avas no detectable phenolsulphonephthalein ex- 
cretion in two hours at the end of six Aveeks of treatment Avhen the pa- 
tient left the hospital against advice. Yet five months later no evidence 
of impaired renal function could be detected. The chief renal lesion 
in bichloride poisoning consists in necrosis of tlie cells of the convoluted 
tubules. This results in marked impairment of the concentrating 2 ioAver 
of the kidney and consequent loss of its ability to eliminate Avaste prod- 
ucts in a small A^olume of ui'ine. A similar renal picture is seen in 
Bacillus 'Welchii toxemia. Shapiro in his description of the renal 
pathology of mercury poisoning states that the tubules regenerate in 
seven days Avith extraordinary activity and rapidity. It is, therefore, 
apparent that the clinical problem as far as the nephrosis is’ concerned’ 
IS to prevent death from acute retention of waste products until time has 
elapsed for regeneration. Although in the second case the Avomen lived a 
month after the onset of the infection, she Ammited daily and did not re- 
ceive sufficient fluids. Perhaps these factors and the pyelitis found on 
microscopic examination prevented a full recovery of the kidneys. 



298 


AMERICAN JOURNAL OP OBSTETRICS AND OrNECOLOGY 


CONCLUSIONS 

1. The early diagnosis of Bacillus Welehii puerperal sepsis is essential 
in order to derive any effect from the polyvalent antitoxin which is on 
the market. It is usually based on the histoiy of pathologic pregnancy, 
labor, puerperium, or abortion. The characteristic observations are 
acyanotic icteric or bronze skin, hemoglobinuria, hemoglobinemia, anuria 
and Bacillus Welehii in cervical smear and culture. 

2. In addition to treating the toxemia, large amounts of hj'pertonic 
glucose (for caloric and diuretic effect), buffer solution and normal saline 
should be given intravenously. 

3. Decapsulation of the kidneys does not seem to be a logical operation 
in view of the pathologjL 

4. The prognosis depends on the establishment of diuresis and thereby 
the elimination of the nitrogen waste products until the necrotic con- 
voluted tubules have regenerated. 

5. The importance of ceiwieal smears and cultures is again demon- 
strated in the diagnosis and treatment of puerperal fever. 

REFERENCES 

(1) Wrigley, A. J.: Proc. Eoyal Soc. Med. 23: Cl, 1930. (2) Schottmiiller, E.: 

Miinchen. med. Wchnsclir. 25; 1817, 1910. (3) Lehmann, W., and Fraenhel, E.: 

Arch. £. GynSik. 122; 692, 1924. (4) Toomhs, P. TV., and Michclson, I. E.: Am. J. 

. Obst. & Gtnec. 15; 379, 1928. (5) Ecim, E.: Zentralbl. f. Gyniik. 48: 119, 1924. 

(6) Cornell, B. S.: J, Infect. Dis. 36: 508, 1925. (7) Barach, A. L., and Braper, 

G.: Proc. Soc. Bxper. Biol. & Med. 24: 411, 1927. (8) Ford, TV. TV., and Lawrence, 
J. E.: Bull. Johns Hopkins Hosp. 38: 245, 1917. (9) Briitt, E., and Lehmann, TV.: 
Klin. Wchnschr. 6: 1510, 1927. (10) Eohl, A.: Zentralbl. f. Gyniik. 52: 1324, 1928. 

(11) Ivens, F.: Lancet 1: 606, 1929. (12) Bats, P., and Mayer, M.: Bull, et mem. 

Soc. med. d. hop. de Paris 53: 1294, 1929. (13) Offer geld: Ztsclir. f. Geburtsh. u. 
Gyniik. 101; 24, 1931. (14) DeEruif, P. E., and BoUman, J. L.: J. Infect. Dis. 21: 

588, 1917. (15) DeEruif, P. E., Adams, T. TV., and Ireland, P. M.: J. Iitfect. Dis. 

21: 580, 1917. (16) Bingold, E.: Ztschr. f. klin. Med. 92: 140, 1921. (17) Say- 

man, J. M., Jr., and Priestly, J. T.: Am. J. M. Sc. 176: 510, 1928. (18) Shapiro, 

P. F. : J. Lab. & Clin. Med. 15 ; 961, 1929. 

30 North Michigan Avenue. 

ABSTRACT OP DISCUSSION 

DE. A. P. LASH (closing). — I caimot give any detailed history as to the origin 
of the serum. The Pasteur Institute was mainly instrumental in producing it, 
following the World War. The bacteria producing gangrenous lesions are com- 
bined to make a polyvalent commercial §tock product instead of having an indi- 
vidual product for each strain. This is possible because the antitoxin for one 
strain will neutralize the toxin of related strains as demonstrated by DeKruif and 
his workers. It seems that if one of these organisms enters the uterus and remains 
there long enough under favorable conditions it will grow and produce necrosis and 
this wiU enhance further groivth of the organisms in the dead tissne and also toxin 
production. 

Anotlier important question is the terminology of puerperal sepsis. As you no- 
tice, my title is, “Puerperal Sepsis: B. Welehii, Patal Types.” I think a better 
picture of puerperal infections is given when a clinical, pathologic and bacteriologie 
term is used which would rule out a lot of the so-called puerperal infections. Some 
of the cases Dr. Palls described may be considered merely infections of the fetuses. 



LASH: PUEKPEBAL SEPSIS 


299 


A clear mental picture is given when one specifies as follows, the type of infection, 
puerperal sepsis, acute metritis and toxemia, B. Welcliii. 

In none of these cases I observed did I notice gas issuing from the vagina or 
cervix. In two, the vaginal discharges were foul. 

The points I tried to bring out are: First, these cases are mistaken because.thpre 
is no gas to give the clinician the impression that he has a gas infection. There- 
fore, it is important to remember, the bronzing of the skin, hemoglobinuria and 
hemoglobinemia, and examining a stained smear from the cervix in order to estab- 
lish the diagnosis immediately. The next important thing is the use of the specific 
serum which must be repeated as long as there is evidence of infection. The next 
thing is dealing with the kidney lesions, by inducing a marked diuresis to remove 
from the circulation the marked amount of nitrogenous end products produced by 
toxic changes occurring in the liver and other parenehj'matous organs. These can- 
not be thrown out in a small amount of urine. This can be produced by pushing 
fluids in the form of intravenous saline, buffer and hypertonic glucose solutions. 

DK. FALLS (closing). — Eeplying to Dr. Bacon as to the percentage of cases in 
which the organisms are found in the vagina of normal women, it occurred to me 
that these must be frequently present in women who are otherwise normal. If we 
are to get patients showing the gas bacillus in a case like the fourth one I reported, 
who was in the hospital for twenty-eight days suffering from decompensated heart, 
and who suddenly aborted without any vaginal manipulation, we think that the gas 
bacillus must have been present before the abortion started. 

The only series of cases of normal women who did not show gas bacillus was at 
St. Vincent's Hospital. These patients come in at about the eighth month of preg- 
nanej’. The highest percentage was in the abortions and that carries the same sig- 
nificance as other workers have pointed out. We had 29 per cent, that is one in 
about three abortions, at the Cook County Hospital. In the prenatal clinic at the 
County Hospital, which is composed of a large percentage of colored patients, we 
found 7.69 per cent, while in the prenatal clinic at the Kesearch Hospital, wdth the 
same type of individual but a little higher grade and more whites, we found only 
4.85 per cent. In the gynecologic department, where the patients are having treat- 
ment and where they are living at home and have a normal sexual relationship, we 
find 33 per cent. Apparently the percentage depends upon the type of patient. If 
we were to take cultures from the private patients we would probably rarely run into 
a gas bacillus. 

The odor of the bacillus has been referred to frequently. I believe that the odor 
and gas production depend on the infection in a late stage of the pregnancy. When 
the fetus is large enough so that gas cannot get out, then the gas will be retained in 
the uterus and will produce physometra. The odor may depend also on an asso- 
ciated anaerobic gas producing streptococcus, and we may have a different odor due 
to two forms of gas being present at the same time. 

As to the virulence of this strain, it has been found that growing gas bacillus 
with other organisms changes its virulence and, if it is found with streptococcus, it 
may not be the streptococcus that causes all the damage, but the presence of 
streptococcus produces an anaerobic condition for the gas bacillus to grow and en- 
hances the production of gas. It is quite evident in these cases that most of them 
are mixed infections. Because the gas bacillus is easy to cultivate, it is apt to over- 
grow. The streptococcus may be very difficult to cultivate and gas bacilli may over- 
p-ow the anaerobic streptococcus and be given the credit for producing death. It 
^ qmte^ significant to my mind that the gas bacillus has not fulfilled the laws of 
Koch wjtli respect to this disease, and that no one has described an epidemic of this 
infection. 



ENTEKOUTERINE FISTULA^ 

With a Review of the Literature and Report of a Case Studied 

Radiologically 

W. G. Danfortii, B.S., M.D., F.A.C.S., and James T. Case, M.D., 
D.M.R.B. (Camb.)? F.A.C.S., Evanston, III. 

(From ihc Dcpariincnta of Ohstctrics and Gynecology and of Fadiology of Forth- 
western University and of the Fvanston Hospital) 

A SURVEY of the literature indicates that enter out erine fistulas are 
not common. We have found reports of 58 cases during the past 
two hundred years in which a fistulous communication existed between 
the bowel and the uterus. Le Jemlel reported a case seen by him in 
1907 and collected 21 others previously reported. He divides the entero- 
uterine fistulas etiologically into three classes: 

1. Ruptures of the uterus, either spontaneous or produced during 
labor. 

2. Pei’itonitis (a) pathologic puerperium, (b) appendicular. 

3. Cancer. 

The explanation of Le Jemtcl as to the mechanism of the production 
of the fistulas seems quite sufficient. 

1. “By strangulation. Iktost frequent in uterine rupture. The intestine enters 
a more or less large tear, ttle uterine contractions strangulate it and the changes 
which follow are those which arc found in a strangulated hernia. Gangrene, estab- 
lishment of protective adhesions, and escape of intestinal contents by the genital 
canal. 

2. “By the simultaneous or consecutive opening of an abscess in the intestinal 
and uterine cavities. MHicther it be a peritonitis follorving puerperal infection or 
an infection following appendicitis, the phenomena are identical. The abscess 
opens but the inflammatory changes have already united the uterus and the in- 
testine, their walls are thinned, without resistance and the couimunicatiou is easily 
explained. 

3. “In cancer of the uterus tlie lesion is about the same, cancerous projections 
springing from the uterus, in incessant contact with the bowel coils, at the level 
of the pouch o'f Douglas, produces an irritation which, little by little produces ad- 
hesion. The cancerous growth infiltrates the intestinal wall, ulceration and loss 
of substance occurs between the intestine and uterus and fecal matter escapes by 
the genital canal." 

The fistulas of carcinomatous origin are apparently far rarer tiian 
those following trauma. The literature of recent years shows a lessening 
frequency of severe obstetric injury followed by enterouterine fistula. 
We have been able to find 37 eases following injury, 14 cases as a result 
of inflammatory processes or congenital lesions, and seven cases of a 
carcinomatous fistula. Our case makes a total of eight reported entero- 
uterine fistulas of carcinomatous origin. 

The Location of the Fistula . — ^In Le Jemtel’s collected series there 
was one case each of a communication between the sigmoid and the uterus 

♦Read at a meeting of the Chicago Gynecological Society, April 15, 1932. 

300 



DANFORTH ^VND CASE: ENTEKOUTERfNE FISTULA 


301 


and betAveen tlie cecum and tbe uterus. He reports three others in Asdiieh 
the exact location of the fistula hr the bowel was not knOAvn. In a,ll 
the other eases in his series the seat of the opening in the boAvel Aims in 
the small intestine. The seat of the opening in the uterus, if the fistula 
folloAA'S an inflammation, is usuallj^ in the fundus. A traumatic fistula 
is located at the point of injury to the uterine Avail. As Le Jemtel 
points out, the size of the fistulous opening varies. A laceration pro- 
duced by the forceps in Avliicli intestine becomes strangulated is much 
larger than the opening produced by the opening of an abscess, AA-hieh 
has formed betAveen Iaa'o structures, AAdiieli are firmly adherent. 

Keugebauer of Warsaw, in 1902 collected 31 cases of enterouterine fistula. A 
jiujuber of Neugebauer’s cases are also reported. he Jemtel, Xn 2 of the cases 
collected by Mm the fistula was found between the stomach and the uterus, in 9 cases 
uterorectal, in 3 cases between tlie uterus and tbe sigmoid, and in one case between 
the uterus and the transverse colon. In 12 cases the small intestine communicated 
wth the uterine cavity. In one ease an opening into the uterus was found from 
both the small bowel and the sigmoid. 

The treatment of fistulas of this Amriety is dependent Avholly upon 
the cause. In those resulting from invasion of the boAvel Avail, by car- 
cinoma originating in the fundus of the uterus, there is ordinarily little 
hope of surgical relief. In the ease here reported the carcinomatous in- 
volvement Avas alreadj^ so extensive that no possibility existed of excision 
of the involA'-ed structures. When a fistula betAveen the boAvel and the 
uterus is found Avhich is a result of trauma, laparotomy may be done 
Avith the hope of freeing the boAvel from the uterus and closing the open- 
ings in the boAvel and uterine fundus, A resection of the intestinal loop 
may be needed. This Avas done in several of the cases collected by 
N’eugebauer Avith success in some of them. In one case, among those col- 
lected by Neugebauer, tbe fecal discharge Avas caused to stop by surgi- 
cally closing the external os of tbe uterus. 

CASE REPORT 

ISfrs. B., aged fifty-eight, entered hospital, October 28, 1931. Married twenty-five 
3 ’ears, AM children. Menopause occurred normally at forty-five. No serious ill- 
nesses until onset of present trouble. At ten years of age she states that she had 
abscess in rectum which evacuated itself spontaneously. About two years ago liad 
eotmdcvablc backache. She has been tre.ated by medical men at times in past two 
or three years for colitis. 

About two weeks ago a discharge began through the vagina of material which 
evidently came from the bowel, food remnants were seen and the discharge was 
not voluntarily controllable. This has continued daily until the time of admission. 
Examination after admission revealed a well nourished woman. Blood pressure 
100/60. Heart and lungs normal. Physical examination essentially normal. 

The vagina was normal. During the e.vamination a sudden 'Sow of material, 
obviously of intestinal origin, containing food remnants, and fluid in character’ 
occurred. Tiio cervix- was small, pointed backward, mobility somewhat diminished’ 
The fundus was irregular in shape, a mass palpable posteriorly and a little to the 
left, mobility diminished. The adnexa were negath'e. 

As no rectovaginal fistula w.-as found to account for the presence of the intestinal 



302 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


contents in the vagina, a speculum ivas introduced ivliich definitely showed that the 
fluid noted above came from the cervix. A uterine sound passed from the cervix, 
passed up through the uterus and apparently to a point beyond where the fundus 
of the uterus should be. Its withdrawal was followed by a small amount of bright 
red fluid blood. 

Proctoscopic Examination . — (By Dr. Charles E. Pope.) The distance observed, 
14 to 15 cm. There is an anterior sigmoid fixation and a sense of a tumor mass. 
No sigmoid or rectal blood. Sigmoid shows marked obstruction from angulation at 
the point of apparent adhesions to the uterus and about 14 cm. from the rectal 
opening. 

Padiologic Examination . — (By Dr. .Tames T. Case.) The patient was placed in 
the dorsal position, a vaginal retractor inserted, and the vagina cleansed of fecal 
matter. An attemjit was made to sterilize the vaginal tract with mcrcurochrome. 



Fig'. 1. — ^Uterine cavity after injection of 8 c.c. of iodized oil. Note the filling 
defect on the right side of the fundus, with irregular contours .indicating a tumor ol 
the fundus intruding itself on the uterine cavity. None of the opaque material had 
passed into the tubes or through the fistula. 

The cervix -was conical, and apparently normal. A cannula -was introduced into 
the cerv'ix for a distance of five centimeters. Everything being in readiness and the 
appropriate instruments at hand, 15 c.c. of opaque oil was introduced into the uterine 
ca'vity with moderate pressure, and control films exposed. These films showed a de- 
formed uterine cavity (Pig. 1), there being a defect of filling in the right anterior 
portion of the fundus in the neighborhood of the right cornu, involving most of the 
right side of the fundus, and being very suggestive of a neoplasm. These films 
showed that as yet no opaque material had passed through the tubes. We ac- 
cordingly prepared the patient a second time, and injected more opaque oil, after 
which further roentgenograms demonstrated that the oil had passed into the cecum 
(Pig. 2), apparently by way of the terminal ileum, although the entire pathway 
was not demonstrable. We assumed that the communication had been with the 
terminal ileum not far from the cecum, because the passage from the uterus to the 
cecum and ascending colon had occurred with such rapidity. The appendix at this 
time was not visualized, and anyhow the distance between the uterine fundus and 


DANPORTH AND CASE: ENTEEOUTERINE FISTULA 


303 


the rather high cecum was too great for the commumcation to have occurred by 
way of the appendix. We accordingly concluded that the lesion in the uterus was 
a carcinoma, and that there had occurred a spontaneous communication with the 
terminal ileum near the ileocecal junction. Another roentgenopam twenty-four hours 
later showed the opaque oil practically all in the colon, filling it from the cecum 
to the splenic flexure inclusive (Fig. 3). The appendix was visualized at the time, 
and further confirmed the conclusion that the fistula had not involved it. A few 
drops of the opaque oil were now noted in the true pelvis, indicating that the left 
tube was patent. 

In view of the septic nature of the contents of the uterus, we felt some anxiety 
about the passage of some of the potentially infected oil into the peritoneal cavity, 
for it is well knoivn that even the high content of iodine in the opaque oil does not 
render it antiseptic; but we reflected that this patient had already ivithstood the 



Fig. 2. — ^The same after further injection of opaque oil. Note the ragged contours 
of the filling defect in the right side of the fundus uteri, still further confirmatory of 
the malignant nature of the tumor ; some opaque oil above the fundus, having passed 
through the left tube; and a considerable quantity of opaque oil in the region of the 
cecum, with a considerable gap between it and the uterine fundus, leading to the 
assumption that the connection was by way of small intestine rather than the appen- 
dix. 

presence of a fecal fistula for some time, and was probably well protected against 
B, coli infection. 

Opcratioji.— November 4, 1931. On opening the abdomen, the terminal coil of 
ileum was found attached to the fundus of the uterus at a point about eight inches 
from the cecum. The entire fundus was greatly enlarged, hard, indurated, and 
nodular, and this indurated feeling extended over into the wall of the ileum. On the 
left side of the fundus of the uterus, just below the point of attachment of the 
ileum the sigmoid was also firmly attached, and this apparently also was invaded 
fvith the same growth. This growth extended out backward and laterally into the 
parametria on both sides. There were apparently enlarged retroperitoneal lumbar 
glands. The entire mass was of slight niobilitj', and unquestionably was a malignant 
affair, probably primary in the uterus. 

Median incision was made, sufficient in length to allow of easy exploration. As 


304 


AJIEKICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


the operation was so extensive as to he accompanied by grave danger, and because 
even an extensive operation Avould still leave retroperitoneal carcinomatous involve- 
ment and probably carcinoma in the parametria, it was decided to do nothing, but 
to close tlie abdomen without any operative attempt being made. The usual closure 
was done ivith stay sutures of braided silk, layer sutures in the abdominal wall and 
running silk in the skin. No laparotomj' pads were introduced. No drainage. No 
anesthetic compUcations. 

The case ■which we present is of interest in that it is the first one in 
whicli radiologic study has demonstrated the site of the fistulous opening 
in the bo'wel. It is true that in most cases the location inaj’- be detei-mined 



Fig. 3 . — Film showing’ disposition of the opaque oil twenty-four hours later. There 
is now no doubt about the identity of the visualized loops of colon. Appendix visual- 
ized, evidently not involved in the fistulous passage. 

■with approximate accuracy by the character of the discharge and pos- 
sibly by the presence of excoriation upon the xmlva. It is also a fact 
that in cases of carcinomatous fistula the fistulous opening is merely an 
event in the later history of a case of carcinoma of the uterus, and that 
attempts at surgical relief are likely to be useless. It has been of in- 
terest, however, to demonstrate that localization of such a lesion radio- 
logieally is possible, especially as it had not been done before. Hyster- 
ography as a routine procedure in carcinoma of the uterus would not 
be a desirable procedure. The possibility of forcing particles of car- 
cinomatous tissue through the tubes into the peritoneal cavity is to be 
feared, and Sampson has drawn attention to the possibility of migration 
of malignant cells from the uterine cavity into the abdomen. Inasmuch 



DANFORTH AND CASE: ENTEROCTERINE FISTULA 


305 


as ill cases in ivliicli a cai’ciiioiiiatoiis fistula already exists, as luucli 
secondary invasion lias alreadj’' occiii'red as is possible, and as tlie pres- 
ence of the fistula itself, allowing the passage of the lipiodal from the 
uterine cavity into the bowel, reduces the danger of the fluid being 
driven through the tubes, it seems a safe procedure. 


REFERENCES* 

4I>MWa(j£e: Soc. Obst. Gynec. de Kj'jew, Marcli 26, 1S97. Amann, J. A.: 
Vei'handl. d. deutsche Gesellseb. f. GynSk. 8; 463-465, 1899. Ashwcll; A Practical 
Treatise on tlie Diseases Peculiar to 'Women, Dontlon, 1845, 520. Didder, A.: 
Verliandl. d. deutschen Gescllsch. f. Chii-. 14: 52-61, 1885; Areb. f. Min. Cliir. 32: 606, 
1885. Bonet, Th.'; Sepulcliretum, Vol. 1, Part ii. Book 3, p. 188, Observation siv. 
Brcitsmaim: Med. Zeitung Preussiebcn Vcrein, No. 26, p. 122, 1844. Bussell; North 
American Medico-Chirurgical Review, 901, 1860. Casamayor, J. A. X. ; J. lieb- 
domadaire de mddeeine 4: 170, 1839. Cohnan: Med. Physical J., Dondoii 2: 262, 
1799. CruveilMm-; Traite d 'anatomie pathologique generale 2 : 533, 1852. Cursham, 
G.; London med. Gaz. 13 -. 943-946, 1834. nahlmanu: Arch. f. Gynak. 15: 122, 
1879. Dmiriac: Societe anat. dc Paris 5: 241, 1891. Bavcxj, J. G.: Lancet 2; 236, 
1835-1836. Davis, David D.: The Priueiplea and Practice of Obstetrical Medicine, 
2: 1072. Demarqiiay: Gaz. Med. de Paris, p. 341, 1867. Dianonx: Bull, et mem. 
Soc. Anat. 71, 1875. Dunn: Trans. Obst. Soc. 9: 65, 1868. Duparque; Gesehichte 
der Durchloeherunger, Einrisse und Zerreisungen dcs Uterus, Vagina und des Peri- 
naenms, Deutsch von Neverinann, p. 4, 1838. JEinhech, A. T.: St. Louis Courier of 
Medicine 4; 122, 1880. Forget: Gaz. med. de Paris, p. 641, 1851. Goth: Arch. f. 
Gynak. 32: 287. Gouin, Gaston; These de Paris, 1903. Graves, TV. P. ; Am. J. 
Obst. 57: 353-354, 1908. Gmscnhauer: Rapport de la Clin. Chirurg. de Liege, Obs. 
186; 210, 1S76-8. Eamou; Rev. med.-chii-. d. mal. d. femmes 7; 455, 1885. Seine: 
Langeubeck'a Arch. 1809. Euf eland: 3. der Prakt. Arzneikunde 9: 131. Ensson; 
Bull, de la Soc. Anatom. 9: 80, 1834. Jones: Dublin J. 26: 162, 1845. Kanfonann: 
Arelu f, Gynak. 28: 407. Kkvisch: Klin. Vortriige ubor Patliologie u. Therapie 
dcs Wciblicheu Geschlechtcs (Edition Scanzoni) 2: 759, 1857. Kuthe, J. P. : 
Nederl. Tijdschr. v. Geneesk. 21: 1889. See Repert. univ. d’Obst. et de Gynic. 
466, 1889. Lamhron, recorded hy Dcneux: These de Paris, No. 278, p. 66, 1804. 
Le Jemtel: Arch. prov. de chir., Paris 18: 028-654, 1909. MacKccver: Practical 
Remarks on Laceration of tlie Uterus and the Vagina, tVith Cases, London, 41-58, 
1824. MacKeevei', Thos.: Trans. Assn, of Pellovrs and Licentiates of the King’s 
and Queen's College of Physic in Ireland, xxxx, 3: 280, 1820, Dublin. MaeKeever; 
Tram, of the Assn, of Fellows and Licentiates of tlie King’s and Queen’s College 
of Physicians in Ireland 3 : 280. Martin Aguilar, Juan (Granada) : Gaceta medica 
do Granada 23; 427-431, 1905. Maslieurat-Lagemard, G. B.: Arch. gen. de mod. 
12; 452, 1836. Mcinert: Verhandh d. deutsche Gesellscli. f. Gyuiik., VI. Kongress, 
Leipzig, p, 283, 1895. Morgan; Western J. M. Sc. 9; 521, 1845. Myasnikof, V.: 
Alcd. Obozr., Mosk. 1: 503-506, 1898. Self eld, B. J.: Primitiae phys, nied. (etc.) 
Zullichoviao 2: 191-193, 1750. NettgeVauer, F. L.: Rev. de gynec. et de chir. abd. 
2: 581-614, 1898. Fennel: France medicale 2; 649, 1881. Feraire: Gynecologie 
16; 101, 1912, Petit, L. E.: Ann. de gynec. 17: 401, 1882; 19; 14, 90, 290, 353, 
431, 1883; 20: 22. BaesynsMj: J. d’Obst. et de Gynec., Saint Petersburg 1201, 
1892 (Russian). Fndford: 'Tram. Obstet. Soc. of London 8: 199, 1866. Foessler: 
Borl. Win. Wehnschr. 440, 1879. Rosenthal, . Gazeta lekarska 13: 581-589 1893 
Routicr; Soc. de aiirurgio, June 10, 1896. Scharlan: Monatsclir. f. Geburtsli u' 
Frauenkrankii., Berlin 27: 1, 1856. Scheneh, Johann: Obsorvationum Libri VII 
Frankfort, 1665, Edition Job. Beyer, Liber IV, p. Q50, Observ. iii. Schenclc W. L.: 

Simon; Moiiatschr. f. Geburtsh. 14: 439, 
ISty. Simpson: Edinburg); iM. J. 11: 875, 1855, cited by Neugebauer. Simpson: 
Clinical Lectures on Diseases of Women, Edinburgh, 1872, p 144 STcinner TF T 

. 1.0, 1830. ^lountschr, f, Gehurtslu u. Fruuenkrankb. 10; 173 1857 

iragcmngc: Ncderlanascho l-ancefc 2; No. 478, 1840; see Kulenkampff Kiel,' 
p. 10/, lSt4. Wood; London Med. Repository 15: 450, 1822. ^ 

636 Church Street. 


and have not 



EEPOET OF A CASE OF CONGENITAL DEFECT IN THE 

DIAPHEAGM- 

Charles Newberger, S.B., M.D., Chicago, III. 

(From the Department of Obstetrics, Mount Sinai Eospital) 

M ES. J. G., thirty-two j’cars of age, married eight years, presented herself in 
the Prenatal Clinic on September 1C, 1931, in the sixteenth week of her first 
pregnancy. 

Her father died in 1917, at tlie age of sixty, in the war zone; her mother, six 
sisters, and three brothers are living. 

She had had measles, diphtheria, scarlet fever, whooping cough, and an opera- 
tion for hemorrhoids. In Januarj', 1927, she was seen in our out-patient medical 



Pig. 1. — Showing arrangement of viscera on opening chest and abdominal cavities. 


clinic for anorexia, loss of weight, weakness, and cougli; she was poorly nourished, 
weighed 80 pounds, and had suspicious findings in the apex of the right lung, pos- 
teriorly. She was placed under observation and treatment, and gradually gained 
slightly in strength, and about fifteen pounds in weight. 

Her menses began at seventeen years of age, were irregular in type, twenty -nine 
to thirty-five days apart, of two or three days’ duration, scanty in amount, and 
painful. 


•Presented before the Chicago Gynecological Society, April 15, 1932. 

306 






NEWBERGER : CONGENITAL DEFECT OF DIAPHRAGM 


307 


She was married in 1924, and in August, 1929, consulted our gynecologic de- 
partment for her sterility. 

Her last menstrual period was May 27, 1931, and she was scheduled to deliver 
March 2, 1932. On her first visit, she complained of occasional headache, dizziness, 
nausea, vomiting, edema, and numbness of her hands. She weighed 98 pounds, and 
appeared rather poorly nourished. Her pelvic measurements were: interspinous, 
25 cm.; intercristal, 28 cm.; intertrochanteric, 30 cm.; external conjugate, 18 cm. 
Vaginally, there was evidence of general contraction of a moderate degree, rvith a 
diagonal conjugate of 11 cm. Wassermann was negative; sputum was negative; 
red blood cell count was 4,800,000; hemoglobin was 75 per cent. She was seen 
regularly during the prenatal period, the blood pressure averaging 120/60, the 
urine showing a trace of albumin on two examinations. At eighteen weeks, she 
was treated for chronic otitis media, and at thirty-two weeks for a mild grippal 



Pig. 2. — Showing absence of kidney and ureter on left side. 

infection. On February 24, a week before term, she weighed 122 pounds, having 
gained 24 pounds in twenty-three weeks. On March 7, 1932, being then five days 
overdue, she was admitted to the hospital for observation. The fundus was found 
eight fingerbreadths above the umbilicus, the fetus was in 0. L. T. position, head 
floating, fetal heart rate 140, blood pressure 88/40, and a trace of albumin was 
found in the urine. X-ray showed a baby of normal contour. 

Pains set in March 9, at 5 AM., and soon were strong and five to six minutes 
apart. Eectal examination at 5:45 am., revealed only 1 cm. dilatation, with the 
head floating; at 10:15 a.m., dilatation was 3 cm., station of the head still high; at 
1:15 P.M., the findings were the same. Because of the generally contracted pelvis, 
the signs of disproportion, the failure of engagement of the head after eight hours 
of good pains, the past medieal history, and the seven years of sterility, with the 
x-r.ay showing a normal b.iby, and the fetal lieart rate 140 and of good quality, 




308 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


low cervical cesarean section was done. A male baby was delivered witliout difficulty. 
It gave a few inaudible gasps, and, in spite of the usual treatment for asphy.via, 
which was kept up for more than an hour, and included the tracheal catlieter, artificial 
respiration, liot bath, adrenalin, lobelin into the cord, and o.vj'gen, it could not be 
resuscitated. While attempting rliythmic compression of the heart and lungs, it 
was noted that the heart beat, which continued for about thirty minutes after birth, 
was present on the right side of the chest, suggesting the possibility of either 
diaphragmatic hernia, or situs' inversus viscerum. 

Autopsy was performed three hours after birth, by Dr. I. Davidsohn, who reported 
as follows: 

Macroscopic . — A white male newborn, 48 cm. long, and weighing 3365 gm. The 
head was perfectly round ; there was no evidence of moulding or compression. The 
hair was well developed. The pupils were "equal and measured 3 mm. in diameter. 



Diaphragm from below showinb 
larxje defect (A) which permitted 
extrusion of viscera into thorax. 


Pier. 3 

The lips were markedly cyanotic. The ears, nose, mouth, and neck, showed no ab 
normalities. No rigidity was present; slight lividities presented posteriorly. The 
umbilical stump measured 4 cm. There was Jio evidence of hemorrhage, or of 
adenopathies. Both testicles were in the scrotum. 

Abdominal cavity . — The liver filled out at least four-fifths of the peritoneal cavitj. 
There was no free fluid. The right diaphragm was pushed downward; the left 
diaphragm was preserved only in its anterior and lateral portions, measuring about 
2 cm. in the widest diameter, and surrounding a large defect througli which one-half 
of the left lobe of the liver, the spleen, the stomach, the pancreas, the entire small 
intestine, and the major portion of the large intestine had entered the chest cavitj 
pushing the heart and left lung into the right half of the chest cavity. The result 
ing position w'as such that the right lung was compressed and covered by the heart, 
which was Ij'ing on the diaphragm. Next to the heart and on its left side was vis 
ible a portion of the spleen covering up the left lung. Then came the large intes 
tine, the appendix being visible in its entire length in the upper part of the neck. 

Ihyvuis . — Weighed 15 gm. and appeared somewhat enlarged; its consistency an 



FISCHMANN: LEUCOPL.AKIA OF VULVA 


309 


appearance were normal. Eeart: tlie muscle and valves showed no abnormaHties. 
Lungs: right, was atelectatic; otherwise it appeared normal; left, was distinctly 
hypoplastic, being about' the size of the middle lobe of the right lung. Spleen, ap- 
peared large, measuring 4 by 3% by 1% cm. Liver : measured 12% by 8% by 4% 
cm. It appeared very much enlarged; its consistency was soft, its cut surface was 
normal. Pancreas, stomach, small intestine, and adrenals: showed no abnormalities. 
Mesenteric lymph nodes: were prominent, but not enlarged. Large intestine; Avas fill- 
ed Avith meconium. Sight Ttidney: measured 4% by 3 by 1% cm. Appeared somewhat 
enlarged; its cut surface, and the right ureter were normal. Left Ttidney and left 
ureter: both Avere absent. Urinary hladder: contained only one, the right, ureteral 
orifice; otherAvise normal. Brain: the external appearance, as Avell as the cut sur- 
face of the formalin-fixed brain presented no abnormalities. 

(Note: The organs Avere left together and therefore not weighed.) 

Microscopic. — Sections of the liver, tliymus, and spleen showed no abnormalities. 

Gross Anatomical Diagnosis. — There Avas a congenital defect on the left side of the 
diaphragm, Avith ectopia of the stomach, pancreas, small and major part of the large 
intestine, spleen, and portion of liver into the chest cavity, with displacement of heart 
and left lung into the right half of the chest. Hypoplasia of the left lung. Aplasia 
of the left kidney, and of the left ureter. 

Comment: The x-ray plates Avere reexamined, but they Avere found to be of no 
value in suggesting the presence of the abnormalities. Tliis case also illustrates the 
simultaneous occurrence of more than one fetal anomaly, and, further, it emphasizes 
the need for insistence of autopsy in cases of stillbirths. If this baby had been de- 
livered vaginally, and no autopsy performed, its death Avould have been charged to 
the obstetric judgment Avhieh attempted such a delivery under the existing conditions. 

310 South Michigan Avenue. 


A CASE OP LEUCOPLAKIA OF THE VULVA FOLLOWED BY 
CAECINOMA DEVELOPING IN THE SCAR OP THE 
VULVECTOMW' 

Dk. E. PiscHMANN, Chicago, III. 

At the last meeting Dr. Culbertson presented a case of leucoplakia of the ATilA’a 
that shoAved carcinoma in the same section. I Avould like to report a case of leuco- 
plakia of the AUilva Avhich Avas folloAved tAvo years later by carcinoma developing in 
the scar follcAAfing vulvectomy for the leucoplakia. This patient presented herself in 
January, 1930, because of intense itching of the vuh’a of one year's duration. She 
AAas then sixty-eight years of age. At that time the A’ulA-a showed considerable loss 
of pubic hair, a great many scratch marks, a number of bluish-Avhite plaques, and 
a parchment consistency of the skin Avith marked atrophy of the labia minora and 
labia niajora and gapping of the external urinary meatus. Because the patient 
preferred surgical treatment, A-ulvectomy Avas done. She was relieved of the itch- 
ing and Avas fairly comfortable until January, 1932, when she presented herself 
again because of bleeding from a small groAvth about 3 mm. in diameter and about 
C mni. above the level of the skin. This tumor Avas rather friable, but she had no 
inguinal adenopathy. At this time Ave resected the tumor and some of the surround- 
ing area and did a plastic; the inguinal glands were also removed by Bassett’s on- 

or -of inn a 


Describoa at a ineetine: of the Chicago Gynecological 


Society, April 15, 1932. 



Society Transactions 


AlilERICAN ASSOCIATION OF OBSTETRICIANS, GYNECOLO- 
GISTS AND ABDOMINAL SURGEONS 

FORTY-FIFTH ANNUAL MEETING 
French Lick Springs, Ind., September 12, 13, and 14, 1932. 

The following papers were presented: 

New Methods of Study Applied to Maternal Mortalities in the Hospital. Dk. 
A. J. Skeel, Cleveland, O. (See page 187.) 

Report of a Case of Myoma of the Anterior Wall of the Vagina. Dr. F. Eedeb, 
St. Louis, Mo. (Published in the current volume of the Society's Transactions.) 

A Study in Correlation of the Sedimentation Test, Filament-nonfilament, and 
the White Cell Count in Gynecology. Drs. H. W. Yates, D. M. Davidow, E. Putman, 
AND F. Ellman, Detroit, Mich. (Sec page 203.) 

Placenta Accreta. Dr. E. L. Dorsett, St. Louis, Mo. (See page 274.) 

Some Observations on Effects of S 3 nnpathetic GangUonectomy of Certain In- 
testinal Conditions. Dr. F. S. Wetherele, Syracuse, N. Y. (Published in the cur- 
rent volume of the Association's Transactions.) 

The Legal Responsibility of the Gynecologist. Dr. E. J. Ill, Newark, N, J. 
(Published in the current volume of the Association's Transactions.) 

Some Phases of the Toxemias of Pregnancy. Dr. B. Solomons, Dublin, Ireland. 
(See page 172.) 

The Relationship Between Exogenous Throat Streptococci and Puerperal In- 
fections. Drs. F. Kellogg, and A. T. Hertig, Boston, Mass. (See page 213.) 

Injury to tfreters, Including Accidental Ligation During Pelvic Operations. Dr. 
Q. U. Newell, St. Louis, Mo. (See page 220.) 

Prevention and Control of Morbidity and Mortality From Puerperal Infection by 
State or Municipal Supervision and Inspection. Dr. C. S. Bacon, Chicago, 111. (See 
page 194.) 

A Report of the End Results of Five Hundred Fifty-Four Consecutive Hysterec- 
tomies. Dr. L. E. Phaneuf and Dr. M. O. Belson, Boston, Mass. (See page 262.) 

The Qualifications of the Specialist. Dr. W. T. Dannreuther, New York, N. Y. 
(See page 165.) 

Uterine Cancer and Its Treatment by Radiiun. Dr. A. P. Leighton, Portland, 
Me. (Published in the current volume of the Association's Transactiono.) ' 

Foreign Bodies Left in the Abdomen After Operations. Dr. J. P. Greenhill, 
Chicago, 111. (See page 231.) 

Sigmoidouterine and Vesicouterine Fistula as a Complication of Childbirth. Dr. 
W. C. G. Kirchner, St. Louis, Mo. (See page 241.) 

Multiple Dermoids of the Ovary. Dr. J. R. Miller, Hartford, Conn. (See 
page 252.) 

Prolapse of the Uterus. Drs. W. A. Coventry, and B. J. Moe, Duluth, Minn. (See 
page 257.) 


310 



CHICAGO GYNECOLOGICAL SOCIETY 

STATED MEETING APRIL 15, 19S2 

Report of a Case of Congenital Defect in the Diaphragm. Dk. Chaeles New- 
BERGEE. (See page 306.) 

A Case of Leucoplahia of the Vnlva rollo-wed hy Carcinoma Developing in the 
Scar of the Vulvectomy. Dr. D. W. Pischmajjn. (See page 309.) 

Enterouterine Eistula, With a Review of the Literature and Report of a Case 
Studied Radiologically. Dr. W. C. Danforth and Dr. J. T. Case. (See page 300.) 

Endometritis and Physometra Due to the Welch Bacillus. Dr. D. H. Palls. (See 
page 280.) 

Puerperal Sepsis: B. Welchii, Patal Types. Dr. A. P. Lash. (See page 288.) 


Dr. William P. Graves, of Boston, Emeritus Professor of Gynecology, 
Harvard Medical School, and a member of the Advisory Editorial Board 
of the Journal, died on January 25, 1933, at the age of sixty-three. 

A more extended obituary notice will be published in the March issue. 


311 





Department of Reviews and Abstracts 

Conducted by Hugo Eheenfest, M.D., Associate Editor 


Selected Abstracts 


sterility and Sterilization 

Moench, G. L.: Methods of Examining Sterile Couples, Jitonatschr. f. Geburtsh. u. 

Gynak. 90: 150, 1932. 

The investigation of sterile couples must be carried out -with great care. The en- 
tire life history of both husband and wife from the time of birth on must be studied 
carefully. This study should include the mode of life, the diet, the frequency of coitus, 
etc. The man is more often responsible for sterility than is usually realized. The 
presence of motile spermatozoa is no indication that a man is normally potent. Moench 
thoroughl 3 ’ studied the morphologic and biometric cliaracteristics of sperm and he 
found that a normal man docs not have more than 19 to 20 per cent of abnormal sperm 
heads and that the coefficient of variability as determined bj’ the curve of the lengths 
of the sperm heads does not exceed 11 to 11.5 per cent. In no case of sterilitj' should 
it be taken for granted that the male is capable of fertilization. Before any manipula- 
tion such as a tubal patenej' test, dilatation of the cervix, curettement, operation for 
retroflexion, etc., is practiced on the woman, the man should be examined even though 
he may have procreated children with another woman or even with the same one. 

J. P. Greenhild. 

Bubin, I. C,: The B61e of Appendicitis in the Etiology of Eemale Sterility, 

Monatschr. f. Geburtsh. u. Gj'nak. 92: ICl, 1932. 

In Rubin’s series of 3,143 cases of sterility there was a historj- of appendectomy 
in 465 cases or 14.7 per cent. Almost 75 per cent of the latter patients had been sterile 
for more than three years. Anticonceptional methods were used by only 10.3 per cent 
of all these patients hence this factor plays a verj* small role in sterilitj-. 

Among the 465 cases, there were 130 cases or 28 per cent of relative sterility. 
Pregnancies occurred in 48 before and in 82 after the appendectomj- and almost half 
of the women who conceived after the operation aborted. 

In 55.9 per cent of the eases the appendix was removed before and in 43.1 per cent 
after marriage. Hence in more than half the cases the male partner can be eliminated 
as the etiologic factor. 

In six cases the patients had been operated upon before the appendectomj- and in 
40 additional cases an operation was performed after the appendix was removed. In 
20 of the 40 operations done after the appendectomj- the tubes or ovaries or both were 
operated upon. 

Hnhner tests performed in 300 cases showed that the spermatozoa were normal in 
only 62 per cent. In 81 of the 465 cases the female genitalia showed signs of hypo- 
plasia. There w-ere 42 cases of retroflexion and retroversion, and enlarged, thickened 
or cystic adnexa in 86 additional cases. 

The author found that appendicitis has a deleterious influence on the ovaries, for 
disturbed ovarian function as measured by disturbances in menstruation occurred in 
32.3 per cent of the interval and in 16.67 per cent of the acute cases of appendicitis. 

312 





ABSTRACTS 


313 


In most instances the disturbance "was in the form of an oligomenorrhea or a 
hypomenorrhea. 

In 306 cases the tubes ■were insufflated and found patent in only 39.5 per cent. 
Pregnancy occurred in 35 of the 306 cases or 11.4 per cent as compared ■with 16 per 
cent for the general group of 2113 patients ■who had Rubin tests. In almost half of 
these cases, conception took place within two months after the insufflation. The author 
concludes that even the mildest attack of appendicitis in a young woman or in a woman 
in the childbearing period should not be considered lightly but an appendectomy should 
be performed as early as possible. J. P. Gkeenhill. 

Moench, G. !■., and Holt, Helen*. Biometrical Studies of Head Lengths of Human 

Spermatozoa, J. Lab. & Clin. Med. 17: 297, 1932. 

Moench and Holt have made a special study of the biometrics of human sperm heads 
with reference to diminished fertility. Of 141 different cases studied, 124 were eali- 
brated. They summarize their work on impaired human fertility as follows : Sterility 
and fertility are not separate entities, the latter being of various degrees and starting 
from a normal, proceeds gradually do^wnward to such low values that clinical sterility 
results. Absolute sterility is much less frequent than commonly supposed, being due to 
gross lesions which in most instances can be determined. In the exact determination of 
the fertility of any given individual, all the factors in the history are almost as im- 
portant as the physical examination. 

By means of careful semen examinations it is possible to determine the degree of 
fertility of any given man. Such examination should include sperm count, motility, 
morphology and biometrics of sperm head lengths. The number of sperms present 
and their motility must be judged very guardedly as purely temporary or accidental 
factors may give rise to misinterpretations. The morphology of the spermatozoa, and 
especially of their heads, seems to be the best and most reliable indication of their 
fertilizing power. The relative number of abnormal heads emitted apparently gives 
a direct index of reproductive fitness of the individual. Thus, no man in the series 
with more than 20 per cent abnormal heads had a good breeding record. Of the simple 
functions of the obtained curves, the coefficient of variation is the most important and 
was seldom much above 11.0 in a normally fertile man ; the upper physiologic limits of 
this function seems to be about 11.5. In every ease where abnormal curves and co- 
efficients of variation above the normal limits or a mathematically significant skewness 
were present, the man’s breeding record was poor. In most cases the morphology of 
the semen and biometrical results ran parallel. In some cases only the morpholog}' was 
bad in others only the biometrics; thus, neither a normal morphology nor a normal 
curve alone moan normal fertility, whereas an abnormal finding in either signifies a 
disturbance of spermatogenesis and, hence, of fertility. When the fertility sinks as 
low as 0.6 of the normal value, clinical sterility usually results. In this series spermato- 
genesis seemed to be most favorably influenced by sexual rest and improvement of the 
general physical condition of the patient. tV. B. Serbin. 

Serdukoff, G.: Restorative Surgery of the Fallopian Tubes. Its Methods and Re- 
sults, La Gynecologie, 31: 193, 1932. 

In the opinion of Serdukoff, tubal sterility in women is much more frequent that 
is commonly believed. The logical therapy of this form of sterility is surgical cor- 
rection which may consist of salpingostomy, implantation, salpingolysis or a combina- 
tion of these. However, every surgical intervention should be preceded by a Rubin 
test or hysterosalpingography for verification of the diagnosis and for localization of 
the obstruction. One must be certain that no infection or inflammation is present. At 
the time of operation, the permeability of the tubes should be checked up. The best 



314 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


results are obtained after salpingostomy, for in the hands of some authors the in- 
cidence of success is 100 per cent. The incidence of favorable results after tubal im- 
plantation varies from 20 to 33 per cent and the technic of this operation is not 
difficult. 

From fourteen to thirty days after operation the tubes should be insufflated or 
iodized oil should be injected into them by waj- of the uterus. When women conceive 
after tliese plastic operations it is best for them to be delivered in a hospital. 

J. P. Greenhill. 

Tschertok, R. A., and Schor, M. I.: Tubal Patency After Intrauterine Injection of 

Iodine, Monatschr. f. Geburtsh. u. Gyniik. 92; 186, 1932. 

In four women, Tschertok and Schor determined that the fallopian tubes were 
patent by means of the injection of lipiodized oil. They then injected 1% c.c. of 5 per 
cent tincture of iodine into the uterine cavity and the subsequent use of lipiodol proved 
that the uterotubal junctions were obstructed. This constituted confirmation of ana- 
tomic studies previously made by the authors. They had found that the injection of 
iodine into the uterus resulted in obstruction of the uterine end of the tube by a plug 
of fibrin. Tliis favored implantation of the fertilized ovum in the fallopian tube, thus 
leading to ectopic pregnancy. Salpingographj' revealed that the obstruction is 
temporarj". However, since the injection of iodine for the purposes of inducing abor- 
tion is by no means uniformly successful, and since it may result in ectopic pregnancy 
and permanent sterility, the authors warn against its use. J. P. Greenhill. 

Vignes, H., and Baron, P.: Experimental Study on the Regeneration of Resected 

Tubes, Bull, dc la Soc. d’obst. et de gynfie. 4: 225, 1931. 

It has been demonstrated that a healthy fallopian tube after being cut possesses a 
remarkable power of regeneration and this is possible even after ligation, double 
ligation and resection, and crushing. Vignes observed such an occurrence in a rabbit 
and decided to study this typo of regeneration and see whether the ovaries exerted any 
influence on it. Vignes and Baron operated upon 30 rabbits. In two rabbits examined 
seventy days after resection of the uterotubal junction and ligation of the ends, the 
tubes were distended by a large amount of serous fluid. Seven other rabbits had the 
same operation but in addition both ovaries were removed. At the end of seventy days 
their tubes were also found to have regenerated. They also contained a fluid but only 
a minimal amount, not sufficient to distend the tubes. In a rabbit with only one ovary 
removed the result was the same as in those not castrated. 

In all cases the regeneration was not quite complete. The author draws attention 
to two facts. First the constant formation of an aseptic hydrosalpinx which distends 
the tubes and perhaps aids in their regeneration. Secondly the fact that the re- 
generation is not influenced by the presence or absence of the ovaries, but there is a 
difference in the amount of fluid secreted following the removal of the ovaries. 

J. P. Greenhill. 

Fuchs, H., and Lork, E. C.: Roentgen Control of Tubal Sterilization, Monatschr. f. 

Geburtsh. u. Gynak. 88: 199, 1931. 

In a series of 73 tubal sterilizations performed on private patients by one of the 
authors (Fuchs) in a period of twenty-six years he encountered only one failure. 
Fuchs and Lork believe that among all the tubal operations recommended for the 
purpose of sterilization two are especially noteworthy: The Madlener method of 
crushing the tubes, and the Menge-Stoeckel procedure in which the tubes are fixed in 
the inguinal canals extraperitoneally. During 1930 they performed 51 tubal steriliza- 
tion operations and examined 35 of the women from three to nine months after opera- 



ABSTRACTS 


315 


tion by means of a salpingogram. In the series of 12 Madlener operations 5 were found 
to be failures anatomically and functionally, hence this procedure is not reliable. The 
strikingly large number of tubal pregnancies which follow the Madlener operation 
justify further restriction of this operation. The Menge operation appears to be sat- 
isfactory but requires more roentgenographic studies. The operation of radical re-^ 
moval of the tubes has proved to be free from failures according to salpingography’' 
but, clinically, failures have been reported following it. Hence the authors feel they 
must agree with Fraenkel’s conclusions, that the only 100 per cent method of steriliza- 
tion is removal of the fundus of the uterus together with both tubes. 

J. P. Geeenhill. 

Naujoks, H.: Reversible (“Temporary”) Sterilization of the Female by Crushing 
the Fallopian Tube, Zentralbl. f. Gynilk. 55: 81, 1931. 

Madlener ’s method of sterilization by means of crushing the tube and ligating 
doubly with nonabsorbable suture material was modified by Walthard, who included 
a slightly larger loop of tube in the clamp. The present author gives a further modi- 
fication as follows : The tube is crushed with a clamp at the ampullic end, for a distance 
of at least 1 cm., care being taken to include both muscle and mucous layers. One must 
be sure that, although the tube is crushed, it is not cut or torn. It is then doubly ligated 
at each end of the crushed area with nonabsorbable suture material. The method is 
advantageous because it is quick, simple, and bloodless, and because it is easily re- 
versible at a later date by simply cutting the tube between the proximal ligature and 
the uterus, either with a knife or an endotherm cautery. 

William F. Mengert. 

Homefifer, L., and Meyerhoff, K.: The Question of Hormonal Sterilization, 
Zentralbl. f. Gynilk. 55: 473, 1931. 

It would be of great value to have an effective safe means of producing temporary 
sterilization. Reasoning that during pregnancy there must be some sort of substance 
which inhibits follicle developuient and ripening, the authors implanted ovaries taken 
from pregnant mice in the thigh muscles of four female mice. Two of these mice be- 
came pregnant after thirty-four and forty-three days, respectively, and the other two 
remained sterile for more than a year. The authors were also able to delay the ap- 
pearance of heat in 21 mice by implanting an additional pair of ovaries, taken from 
nonpregnant mice, in the thigh muscles. However, they do not believe that these ex- 
periments present clear proof of hormonal sterilization and feel that further researches 
must be made to clarify the problem. William P. Mengert. 

Mendelshtam and Tschaikovsky: Hormonal Sterilization of Animals, J. akush. i. 

zhensk. boliez. 42; 757, 1931. 

The authors used prolan of the kloscow Endocrinological Institute in which prolan 
B is predominating. Seventy-three female mice were injected with 10 mouse units of 
prolan in single dose. After four days they were put with male mice for mating 
and stayed together fifteen days, and then were separated. After twenty-four days 
(counting from the first day of mating) it was found that there were eleven pregnant 
mice. Of the sterile mice, three were killed. On histologic examination many corpora 
lutea (vera and atretica) were found. 

Pour days after injection of prolan in two control mice both ovaries were found 
luteinized. By this single injection of prolan the ovulation in mice was discontinued 
for five to six mouse cycles. 

The authors think th.at prolan may some day be used for temporary sterilization 
of women. Alexander Gabrielianz. 



316 


AMKRICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


Tschaikowsky, V. K.: Sterilization of Animals Without the tTse of Hormones, J. 

akush. i. zhensk. boliez. 42: 758, 1031. 

The author injected eleven female rabbits and eighty-nine mice three to four times 
■with isogenic protein of placenta free from hormone. No rabbits became pregnant. 
After thirty-five days (from the first day of mating) only two mice were pregnant. 

Injection of this same protein into pregnant rabbits led to abortion. 

Histologic examination of ovaries revealed death of the ovum in aU stages of ripen- 
ing of the follicles. In the liver and kidneys no signs of toxicity were found. Some 
changes -u'ere found in the thyroid gland. Five rabbits were further observed in which 
sterility lasted from two to five months. The offspring of these animals were born 
at term and were healthy. Alexander GjUsrielianz. 

Unhehaim: The Effect of Nicotine on the Ovaries of White Mice, Arch. f. Gynilk. 

147: 371, 1931. 

The author found that subjecting white mice to nicotine poisoning resulted in the 
production of definite pathologic changes in the ovaries. Estrus was always definitely 
delayed. Histologicall)’ the ovaries, following nicotine poisoning, showed degenerative 
changes in the ripening follicles together with a definite decrease in the number of 
atretic follicles. Tlie connective tissue of the interstitial portions of the ovaries ■was 
always definitely increased. Cyst formation ■was never found. Ealph A. Beis. 


AMERICAN BOARD OP OBSTETRICS AND GYNECOLOGY 

The next written examination and review of case histories ■will be held in cities 
throughout this country and Canada where there are Diplomates who may be empow- 
ered to conduct the examination, on April 1, 1933. 

The next general, clinical e.xaniination is to be held in Milwaukee on Tuesday, June 
13, 1933, immediately preceding the annual session of the American Medical Associa- 
tion. Eeduced railroad rates will apply. 

The Diplomates of the American Board of Obstetrics and Gynecology in attend- 
ance at the coming scientific meeting of the American Medical Association in Mil- 
waukee, June 14 to 16, ■udll hold a dinner and Bound Table Conference on the evening 
of the first day of the scientific session, June 14, at the Hotel Schroeder. At this 
dinner, the successful candidates certified at the preceding da}''s examination will be 
introduced in person. A short address ■will be made by one or more of the Board offi- 
cers, and a general discussion of Board activities ■will follow. Diplomates of the 
Board are urged to attend and to bring any interested guests. The subscription for 
the dinner will be nominal and reservations may be made in advance through the 
Secretary’s office. 

Early application is requested from those desiring to qualify for these examina- 
tions. For further information and application blanks address the Secretary, 1015 
Highland Building, Pittsburgh, Pennsylvania. 




William Phillips Gratos 

1870-1933 






318 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


through by tutoring and Avinning a scholarship, shoAA’ing his ability and 
energy by graduating at the head of his class Avith a summa mim laude de- 
gree in 1899. As a second year student he cut himself AA'hile doing an au- 
topsy on a scarlet fcA'er A'ietim and nearly died from the hemorrhagic tjTie 
of that disease. 

After a j^ear as interne at the Massachusetts General Hospital he mar- 
ried and AA’ent to Europe for study, principally in pathology under Storek 
at Vienna. 

In 1902 a place Avas offered him at the Free Hospital for Women AA'here 
he established the pathologic laboratory and then Avent to Baltimore and 
other cities for six months’ study and obserA’ation. At Johns Hopkins he 
reeeh’-ed inspii-ation from Kelly and Cullen as Avell as learning the technic 
of medical illustration from the famous Max Brbdel. 

His progress from then on AA'as steady and brilliant. He became Sur- 
geon-in-Chief to the Free Hospital for Women in 1908 from AAdiich he re- 
tired on reaching the age limit on Januai-y 1, 1933. He A\-as the Professor 
of Gynecolog.y in the IlarAuird UnWersity IMedical School from 1911. The 
late Dr. William H. Baker left a fund establishing a professorship in gyne- 
cology to be knoAA’ii by his name to Avhich Dr. GraA'es A\’as appointed in 1926. 
He resigned this post in 1932, becoming Professor Emeritus. 

Dr. GraA'es made many contributions to medical literature but his 
croAvning achicA'cment AA-as the AA'ell planned, clearly AA'ritten textbook on 
gynecology Avhieh first appeared in 1916. Its popularity may be gauged by 
the fact that it has been translated into other languages and that he aa’rs 
engaged in preparing the fifth edition at the time of his death. 

He belonged to many medical societies, local, national, and foreign. Bos- 
ton Unwersity honored him AAuth the degree of Doctor of Science in June, 
1932, and in December, 1932, he A\'ent to England to recede an honorary 
felloAA'ship in the British College of Obstetricians and Gjuiecologists. 

Soon after his return from England he contracted the prevalent acute 
infection of the “grippe” type but, AA’ith his characteristic sense of dutj’", 
he insisted on getting up to operate on a case already scheduled. That AA’as 
CAudently too great an exertion and after tAA'o Aveeks of acute illness he died 
on Januaiy 25, 1933. He is surviA'ed by his AAudoAA" and three children, one 
of AA'hom, Sidney C. GraA^es, had just started to practice in association AAuth 
his father. 

Dr. Graves ’ outstanding characteristics to his associates Avere his cease- 
less energy based on a magnificent physique ; his intense ambition to knoAv 
all that there Aims to knoAv about any subject that interested him ; his tenac- 
ity in adhering to AAdiat he thought Avas I'ight ; and his conscientious care of 
his patients. 

He was a man of many attributes, a first class’ surgeon, a good painter 
and modeler, and a person of AA’ide culture. He Aims greatly interested in 
philosophy and psychology, Avriting and reading papers on those subjects. 



WILLIAM PHILLIPS GRAVES 


319 


Everything that he turned his mind to was studied tlioroiighly. For in- 
stance a lecture which he gave on the technic of golf some years ago was 
complete in every detail from subject matter to illustrations. His real 
avocation was to work just as hard at whatever attracted him as he did at 
his vocation. However when he felt free of care he was an extremely com- 
panionable man who enjoyed having a good time. His conscientiousness 
is illustrated by the many times that he gave up meetings of the American 
Gynecological Society and class reunions, to which he had looked forward 
with anticipation, because he felt that some sick patient needed his 
presence. 

An excellent perspective of his career is given in these words of Profes- 
sor Blair Bell ivhen conferring the honorary fellowship in the British Col- 
lege of Obstetricians and Gynecologists. “Professor Graves. In this 
world of haste and hurry, conditions not unknown in your country, you 
stand out in our branch of medicine as a man of quiet contemplation, of 
wise discretion and of sober judgment. Your influence on the pi-ogress of 
obstetrics and gynecology has been profound, not onlj’- in the United States 
but wheresoever there exists a parcel-post for the transport of your class- 
ical works. You are an artist both in practice and in theory. The beauti- 
ful illustrations drawn by your own hand which adorn your papers and 
books are the admiration of all. You bring artistry to your craft. You are 
too a thinker and hidden under a deep reserve lie golden thoughts. In 
honoring you we honor obstetrics and gyneeologjL ’ ’ 

— Frank A. Pemherton. 



Original Communications 


LESIONS OF THE PLACENTiLL VESSELS'^' 

Their Relationship to the Pathology of the Placenta ; 

Their Effect Upon Fetal Morbidity and j\Iortality 

Thaddeus L. Montgoaiery^ M.D., Philadelphlv^ Pa. 

(From the Department of Ohstetrics, Jefferson Medical College Eospital) 

'^HE purpose of this paper is to describe eertain lesions of the placental 
vessels, to discuss their relationship to otlier pathologic conditions in 
the placenta, and to consider their effect upon the morbidity and mortalitj’- 
of the fetus. Tlie material which has been emploj'ed in the study consists 
of the placentas delivered in the Obstetrical Department of Jefferson Med- 
ical College Hospital during the past three years. Pour hundred consecu- 
tively delivered placentas were suh.iected to microscopic study. Prom the 
remaining specimens, histologic sections were cut only in those instances 
in which there were obstetric complications or gross evidence of pathology. 
Of these there were 250. 

Within the brief scope of the paper it is obviously impossible to include 
all the lesions which occur in the vascular structures of the jdacenta. I 
propose, therefore, to limit the discussion to acute inflammation and to cer- 
tain alterative and obliterative lesions. The condition of the vessels in 
syphilis of the placenta will be dealt with at another time. 

ACUTE INFLAJIJIATION 

Our knowledge of acute inflammation of the placenta has been enhanced 
by the contributions of Warnekros, Siddall, Slemons and others. A num- 
ber of enlightening papers have been published in recent years. Special 
staining methods have revealed the presence of bacteria, frequently of a 
pathogenic type, in association with the histologic lesions. In a contribu- 
tion to the mechanism of intrauterine infection and to the pathogenesis of 
placentitis, Kobak has made a careful study of the histopathology, and has 
recorded the results of cultures collected from the fetal cord blood. In 
many instances he demonstrated the presence of pathogenic organisms in 
the blood stream of the newborn child. Wohlwill has discussed the con- 
dition, Avith particular attention to its occurrence in abortion. 

In our oAvn series acute inflammation of the membranes, of the placenta 
or of the cord vessels ivas found in 67 specimens, or 10 per cent of the 650 
placentas. The first site of inflammatory reaction occurs in the mem- 

*Kead at a meeting of the Philadelphia Obstetrical Society, May 5, 1932. 

Note: The Editor accepts no responsibility for the views and statements of authors 
as published in their ‘ ‘ Original Communications. ’ ’ 

320 



MONTGOMERY: LESIONS OF PLACENTAL VESSELS 

branes, particularly at tlie margin of the aperture and adjacent to the 
cervical os. The inflammation is evidenced by a polymorphonuclear leu- 
cocytic infiltration of the subamniotic and chorionic layers (Eig. 1) . In 
the mild eases there is no evidence of extension to the placental tissue. In 



Fig. 1. — Acute inflammation of tlie membranes. Extensive polymorphonuclear leu- 
cocytic infiltration and fibrinous deposit as revealed under the high power objective. 
(Photomicrograph 207X.) 



f 1'"°™ nie’^mbranesH’o the^forrespond^ng'^la^^’rs of^tn infiltration e.x- 

( Photomicrograph 57X.) espondmg layers of the margin of the placenta. 






322 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


tlie modei'ately advanced cases of acute inflammation, the inflammatory 
reaction extends to the margin of the placenta and involves the correspond- 
ing layers of the latter organ (Fig. 2). The reaction extends only a short 
distanee along the decidual laj-er of the placenta, but is found almost uni- 
formly throughout the subamniotie tissue. The blood vessels -which trace 
across the fetal surface of the placenta are frequentlj* involved (Fig. 3). 



Pig. 8. — Acute inflammation of a large placental vessel. Leucocytic infiltration of the 
intima, the muscle wall, and the perivascular tissue. (Photomicrograph 40X.) . 



Fig. 4. — Acute thrombophlebitis of cord vein. Leucocytic Infiltration in the inter- 
stices of the muscle wall and intima. Meshwork of fibrin and leucocj’tes. projecting into 
the vessel lumen. (Photomicrograph 227X.) 





323 


MONTGOHERT: LESIONS OF PLACENTAL VESSELS 

unaffected. Inflammatory reaction m the vein is similar m appearance 

to that in the vessels of the placenta. • , . . , i 

If the inflammation is more severe and extensive, thrombosis takes place. 

The cord vein always contains a more advanced grade of thrombosis than 
the arteries (Fig. 4). As a general rule the placental villi, villous capi - 
laries, and small vessels of the villous stems are free of inflammatory 

reaction. 



Fig. 5. — ^Focai necrosis of placental villus. Fibrin deposit surrounding a villous stem 
in which the vessel is of normal histologic structure. (Photomicrograph 230X.) 
A. Fibrin deposit. B. Normal villous vessel. 


Judging from the obseiwations of others and from a consideration of 
our own cases, it appears that this acute inflammation in the fullterm pla- 
centa and cord vessels develops during the course of labor and is the result 
of an intrapartum infection. Premature rupture of the membranes, pro- 
longed labor, difficult labor with operative vaginal delivery, and repeated 
vaginal examination constitute important predisposing factors. The con- 
dition is often associated with an intrapartum fever. In abortion and 
miscarriage the occurrence of inflammation is relatively more frequent 
than in fullterm labor. 

Considering the nature of the process, particularly in those instances in 
which particles of thrombi become detached from the cord vein and enter 
the fetal circulation, an increase in morbidity and mortality of the fetus 
IS to be expected. As a matter of fact, it is surprising that a great many 
more babies do not succumb to the effect of the bacteremia. In those in- 




324 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


stances in M’liieli death of the newborn oceurs, it is nsnallj’- difSeult to de- 
cide -whether the fatal outcome is the result of prolonged labor and difficult 
vaginal delivery, or the result of the plaeental bacteremia. In some in- 
stances it appears that the t-wo factors are conjointly responsible. 

In one of the most severe cases of placental and cord inflammation which 
I encountered in the series, the patient had been in labor for twentj’-'four 
hours on the outside, had been subjected to several vaginal examinations 
and an attempt at forceps delivery, and was eventuallj’- delivered by for- 
ceps in the hospital. The baby succumbed two days later. Autopsy re- 
vealed the presence of a purulent collection in the anterior lobe of the brain 
and multiple pyemic foci in the lungs. In this instance cerebral trauma 



Pig. G. — Conglomerate necrosis (infarction) of the placenta. Group of villi amalga- 
mated by fibrin deposit, tlieir syncytial covering lost and the stroniii degenerated. (Photo- 
micrograph 92X.) A. Degenerated villi. B. Fibrin deposit. 

formed a nidus for the lodgement of the organisms tvliich tvere present in 
the fetal circulation during the course of labor. 

That a fatal outcome for the baby does not occur more often is attribut- 
able to the facility with which fetal tissues destroy and eliminate bacteria 
from the blood stream. "When the cord is ligated and the fetus detached 
from the source of the bacteremia the dangerous period of the infection is 
passed. 

ALTERATIVE AND OBLITERATIVE LESIONS 

Those lesions of the placental I’^essels which are of a chronic nature, the 
alterative and obliterative types, require more careful consideration. The 
presence of such vessel changes has long been recognized. In 1897 Eden 
wrote a splendid description of the histologic picture of endarteritis oblit- 
erans of the placenta, a description to Avhich little can be added. 




mo.xtgomert: lesions of placental vessels 325 

HoAvever as to tlie significance of these chronic lesions and their rela- 

tioXto’other pathologic conditions of the — 

hP said Eden and others considered endarteritis obliterans a cause ox 
^^^infattion’’ of the placenta. Various other placental disturbances, and 
iittcrine death of the fetus ivere ascribed to the Ba«e. T^d.- 
tuni was formulated that a placenta is as old as its blood vessels Thus the 
life cycle of the placenta was described in terms of vessel sclerosis an 
obliteration. It is with such problems that the remainder of my paper is 

'"'"Tlmretie certain areas of the normal placenta and certain lesions of the 
placenta in which ‘ ‘ chronic ’ ’ vascular changes are frequently found. At 



Fig. 7. — ^Necrosis at the marg-in of the placenta. Note particularly the obliterative 
changes in the vessels oJ this zone. (Photomicrograph 57X.) A. Physiologic oblitera- 
tion of placental vessel. B. Fihrin deposit. C. Regenerated villi. 


the margin of everj" f ullterm normal placenta, there is recognizable a zone 
indicating the point of transition from the chorion frondosnm, which later 
becomes the fully developed placenta, to the cliorion laeve, which later en- 
ters into the formation of the membranes. In this zone there are present 
degenerated villi associated irith intervillous fibrin deposit. The fetal ves- 
sels in such areas are either completely obliterated or greatly reduced in 
caliber (Pig. 7). Apparently, the vessel obliteration is due to collapse of 
the muscle wall and growth of the intima until the lumen is completely 
obliterated. Frequently the obliterated vessels in this region" have under- 
gone such extensive hyalin degeneration as to make it impossible to recog- 
nize any detailed structure of the vessel. 

Another site in which vessel alterations are observed is the conglomerate 
necrosis (infarction) of the fullterm placenta. Microscopic study of siich 



326 


AJIERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


areas reveals a liyaline degeneration of the villons stroma, a loss of, or 
necrosis of the OA'^erlying chorionic epithelium, and a dense deposit of fibrin 
in the intervillous space (Fig. 6). The vessels in such areas are usually 
small in caliber, the lumina are obliterated or greatly reduced in size, 
granular and h.yalin degeneration are present in the muscle wall, and fre- 
quently a growth of the lining intima completely seals the vessel lumen. 
Occasionally, however, vessels which are normal in size and which contain 
a few degenerated red blood cells arc observed. Such areas of necrosis are 
present so uniformly in fullterm placentas that the lesions are considered 
physiologic. 

There are, however, similar but more extensive lesions of placental 



Fig. 8. — Histologic structure ot the placenta of missed abortion. The villi are large, 
of the immature type. The chorionic epithelium has been destroyed. Intervillous fibrin 
deposit is extensive. (Photomicrograph 72X.) 

necrosis tvliich interfere with the growth and vitality of the fetus. They 
are associated with certain instances of missed abortion, with massWe in- 
farction of the placenta and intrauterine death of the fetus, and with intra- 
uterine death of one of the fetuses of binovular twins. 

In the presence of large areas of necrosis of the placenta, the functional 
capacity of the organ is so decreased as to lead either to immaturity or to 
intrauterine death of the fetus. The placental vessels Avhich supply these 
areas are either collapsed or obliterated, revealing endovascular alteration. 
The lai’ger the area of “infarction,” the larger the vessels that are in- 
volved. In such instances when the vessels of the placenta are distended 
with an opaque fluid, the x-ray reveals areas in which circulation is absent 
(Fraser). 

A similar appearance is found in certain cases of missed abortion. A 




327 


MONTGOMERY: l.ESIONS OF PLACENTAE VESSELS 

T^liotomicroffrapli wliicli I present in this series is taken from a specimen of 
mteTabo^^ -as secnred at five lunar months. At four Innav 
months the nterus ceased to grow, and during the last month decreased 
progressively in size. The Aschheim-Zondek and ^ 

Ihich had been positive early in pregnancy, became negative Sensation 
of movement Mhich had been experienced in slight degree disappeaied 
The patient experienced no abdominal pain and no vaginal bleeding, ihe 
contents of the uterus were removed by dilatation and evacuation an ^ a 
small mummified fetus and necrotic placenta obtained. The placenta re- 
veals upon microscopic examination changes quite similar to those of mas- 
sive necrosis of the fullterm placenta. The villi are large in construction, 



Pig. 9. — ^Vascular lesion in placenta of missed abortion. The intima is thickened. 
Fibroblasts are invading the vessel lumen, and inaugurating the process of organization. 
(Photomicrograph 102X.) 


such as one expects to find in an early pregnancy, and have undergone 
complete hyalin degeneration (Fig. 8). The intervillous deposit is quite 
heavy, and obliterative changes have begun to take place in the fetal ves- 
sels. In many instances the degenerative process is so marked that the 
anatomic details of the vessel are obliterated. In the instance of one of the 
larger subamniotic vessels of the placenta the growth of new tissue arising 
from the intima is quite well shown (Fig. 9) . 

In addition to these several examples, there have occurred during the 
last eighteen months four instances of binovnlar pregnancies in which one 
fetus was born alive at or near term, with a corresponding normal pla- 
centa, Avhile the other fetus was born dead, macerated and compressed, at- 
tached by a necrotic cord to a placenta which Avas extensively degenerated. 
Of the tAvo specimens of this condition Avhich I AAush to present one Avas ob- 




328 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


tained from a case of binoviilar twins and the second from an instance of 
binovular triplets (Fig. 12). In the instance of the binovniar twins the 
contrast between the histology of the normal placenta and the degenerated 
placenta is clearly shown in Figs. 10 and 11. In the instance of the binov- 



Pig. 10. — Histologic section ot the undegeneratcd placenta of binovular twins. The 
villous stroma is slightly more dense than in the average fullterm placenta, but there is 
no evidence of necrosis of the chorionic epithelium. (Photomicrograph 156X.) 



Pig. 11. — Histologic section of degenerated placenta of binovular twins. The syncy- 
tium has been lost. Intemdllous deposit is extensive. There is hyalin degeneration of the 
villous stroma. (Photomicrograph 72X.) 






MONTGOMERY: LESIONS OF PIACENTAL VESSELS 


329 


ular triplets the living ehikl was born at full term anti a few moments 
later two other degenerated and necrotic fetuses were expelled. Upon de- 
itery of the plaeentas it was found ftat the dead fetuses were at aehed to 
a single placenta in which the circulations communicated while the livm 
fetus was attached to an entirely separate placenta ^ig. 12) . ® 

the male sex. The photomicrographs show quite distinctly the diifeiene 
in character of the two plaeentas, one revealing the normal delicate struc- 
ture of the placental villi and vessels, the other a granular degeneration ot 
the chorionic epithelium with calcareous deposits on the surface of t le 
villi (Figs. 13 and 14). 

In the specimen of the degenerated placenta of triplets there are re- 
vealed so clearly the various stages of obliteration of placental vessels, that 



Pig:. 12. — The macerated fetuse.s and the placentas from binovular triplets. The dead 
fetuses are attached to a single placenta which is small, smooth, thin, and indurated. To 
the larger placenta the living fetus was attached. 


I have chosen from it several sections. The photomicrograph discloses 
a growth of intimal cells which either reduce the caliber of the vessel to 
several small channels, or practically obliterate the lumen (Fig. 15). ‘ 

These eases are representative of rather numerous instances, in Avhich, 
with extensive necrosis of the placenta a profound effect upon the vitality 
of the fetus is encountered. 

It is much easier to demonstrate the existing pathology than it is to ac- 
count for the mechanism of its production. After studying these condi- 
tions carefully from the standpoints of clinical observation and histologic 

examination there are certain views which I, nevertheless, desire ^o 
present. 

In the first place, I am forced to disagree Avith the conception that these 
lesions are the result of, or secondary to the atrophic and obliterative 
changes in the placental vessels. In this connection I Avould refer briefly to 




330 


A^lERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


a previous paper iu vliicli this matter was discussed (Montgomery) . I am 
now rather decidedly of the opinion that the life cycle of the placenta is 
written, not in terms of vessel change, hut in terms of the aggression and 
regression of the chorionic epithelium. The life c^mle and the nutrition of 
the chorionic epithelium appear to be independent of the fluid in the fetal 



Pig. 13. — Structure of the undegenerated placenta in binovuiar triplets. Note the normal 
delicate architecture of the placental vessels, and villi. (Photomicrograph SOX.) 



Fig. 14. — Structure of the degenerated placenta In binovuiar triplets. Granular de- 
generation and hyaline necrosis of the chorionic epithelium and vilious stroma uitii 
numerous areas of calcareous deposit. (Photomicrograph 127X.) 






331 


MONTGOMERY : LESIONS OF PLACENTAL VESSELS 

vessels. Nunierous observations confirm this conclnsion. In the first 
place, at the time when the trophoblast is most active and the cellular 
hyperplasia of the ectoderm most marked, there are no fetal vessels present 
in the mesoblastic core. In the second place, the chorionic epithelium ap- 
pears capable of sustained life when it is detached from the villous core, as 
demonstrable in tubal pregnancy and chorionepithelioma. In the third 
place, in certain conditions, such as syphilis of the placenta, in which the 
villous capillaries are quite small and apparentlj’^ inadequate in size, the 
chorionic epithelium retains its vitality. Finally, in the examination of 
early cases of focal necrosis of the placenta, degeneration of the syncytium 
and fibrin deposit occur on villi in which the villous circulation is undis- 
turbed (Fig. 5 ) . 



Pig. 15.--EndoyascuUtis of placental vessel. The growth of vascular connective tis- 

several small endothelial lined channels. 
(Photomicrograph 207X from the necrotic placenta of the binovular triplets.) 


The active growth of the trophoblast duinng the early period of preg- 
nancy, the gradual loss of activity during tlie mid-period of pregnancy 
and, finally, the thinning out and atrophic change in the chorionic epi- 
thelium in the latter part of pregnancy constitute one of the numerous 
cyeheal phenomena which characterize the higher animal. 

When the chorionic epithelium is subjected to conditions which impair 
its growth activity or withhold its nutrition, pathologic disturbances, such 
as cxtensnYecrosis, take place. The parenchymatous structure of the 
placenta is then destroyed, either in local or widely diffused areas. The 
collapse and obliteration of the corresponding placental vessels occur sec- 
1 1 ^ 1 constitute a readjustment of the amount of circulating 

blood to the decreased circulatory requirements. This interpretation is in 



332 


AJIERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


keeping witli our present knowledge of the plij’’siology of reproduction and 
can be applied to each of the types of placental necrosis which have been 
considei'ed. 

The necrosis which is found at the margin of the placenta is the result 
of inadequate nutrition at the zone of transition between the richly vascu- 
larized decidua serotina and the thin, pooity vascularized decidua eap- 
sularis. The villi in and adjacent to the chorion laeve undergo, in reality, 
starvation necrosis; the associated fetal vessels, a gradual and complete 
secondary obliteration. 

“Infarction” of the fullterm placenta is due to the fact that the 
chorionic epithelium has at this period of pregnancy undergone such ex- 
tensive regression that it no longer acts as an adequate vascular lining to 
the intervillous spaces. As a result, areas of fibrin deposit take place upon 
the exposed and degeneivated surfaces of tlie idlli. When such areas ex- 
tend, large groups of villi are thrown out of function and the correspond- 
ing fetal vessels collapse and undergo degenerative and obliterative 
changes. 

These two lesions, necrosis of the margin of the placenta and “infarc- 
tion” of the fullterm placenta, are considered normal manifestations of 
the life history of the organ. However, a consideration of those necrotic 
lesions which give rise to missed abortion, intrauterine death of the fetus, 
and to the death of one of binovular twins, impresses one with the fact that 
he is dealing in these instances with notable departures from the normal. 

In explanation of the etiology of such abnormalities several factors must 
be considered. The first of these is that the endometrium may be improp- 
erly prepared for the reception of the OAuim, or that the decidual bed may 
be subsequently impoverished by degeneration or by thrombosis of the 
uterine vessels. Recent studies in obstetric and gjuiecologic physiology 
have demonstrated how necessary it is that the endometrium be properly 
prepared for the reception and implantation of the fertilized o^uim. Nor- 
mal corpus luteum secretion appears essential for the development of the 
pregravid stage of the endometrium and for the continuance of pregnancy, 
at least during the early weeks. Comparatively little is known, however, 
of the part that this and other inteimal seci’etions play in the further main- 
tenance of the intrauterine life of the fetus. 

Practical experience, however, demonstrates how essential the activity 
of the thyroid gland is in the maintenance of normal fetal growth. For ex- 
ample, obstetricians generally have found the empiric use of iodine or 
thyroid extract of value in promoting fullterm pregnancy, particularly 
in those patients who have repeated^ suffered abortions or stillbirths. 

It appears problematic, however, whether the character of the site of 
implantation alone governs the nidation and normal groivtli of the ovum. 
For instance, in placenta aeereta the noz'mal decidual layer between the 
epithelium and the uterine musculature is absent. In those instances 
where the chorionic epithelium is hyperactive, namely, in chorionepitheli- 
oma and in hydatidiform mole, the epithelial cells invade all tissues with 



MONTGOMERY: LESIONS OE PIjACENTAI. VESSELS 


333 


little respect for previous preparation. Indeed, if internal secretions and 
their effect upon the implantation site of the placenta are alone responsible 
for the grovdh of regression of the placenta, why should the line of dif- 
ferentiation be so clearly marked between the necrotic placenta and the 
normal placenta of binovular twins ? In the one case there is a completely 
normal placenta and in the other there is a uniformly degenerated 

placenta. 

The character of these various lesions suggests that the ability ot the 
fertilized ovum to grow and maintain its existence in the uterus is depend- 
ent not only on the site of implantation, but also on the innate nature of 
the germ plasm. The latter conception offers a more reasonable explana- 
tion of those instances in which early necrosis of the placenta takes place 
with missed abortion, and of those instances in which the one fertilized 
ovum of binovular twins proceeds normally in its growth, while the other 
fertilized ovum advances only to a limited stage of development and suc- 
cumbs. Some such explanation also lies at the foundation of chorionepi- 
thelioma, in which the growth impulse of the fertilized ovum and its de- 
rivatives far exceeds the normal. 

These matters require experimental study. It is of the greatest im- 
portance to determine if the internal secretions of the anterior lobe of the 
hypophj^sis and thyroid gland which appear so necessary in the prepai’a- 
tion of pregravid endometrium are equally necessary for the activation 
and sustained growth of the ovum and its derivatives. 

While it appears manifest that placental vessel obstruction is not the 
cause of necrosis of the placenta, nevertheless for the confirmation of more 
rational conceptions, further biologic studies are essential. 

SUMMARY 

1. A brief outline of the acute inflammatory reactions of the placenta 
and placental vessels has been presented. It has been shown that the 
milder t 5 rpes of acute inflammation begin in the membranes. The margin 
of the placenta and the amniotic surfaces of the placenta are next involved. 
When the inflammation is more advanced, a leucocytic infiltration of the 
placental vessels and cord vessels takes place ; in the severe or extensive 
types of inflammation, thrombosis occurs. Only in the most severe types 

of inflammation does the condition in the placenta react unfavorably on 
the child. 

2. Certain placental vessel lesions of an alterative or obliterative type 
have been studied. They are found present with necrosis of the placenta. 

le vessel lesions appear secondary to degeneration of the chorionic epi- 
thelmm rather than primary. This is tme not only when necrosis is of the 

3 The dictum that “the placenta is as old as its vessels” is not appli- 
cahle; in reality, the placenta is as old as its chorionic epithelium 
4. Certain views are presented as to the cause of premature and exten- 



334 


AIMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


sive necrosis of the placenta. These are based upon clinical and histologic 
studies. The most likely explanation appears that the fertilized ovum, 
either because of hereditarj' influences or because of the effect of internal 
secretions, departs from the normal in its gi’owth activity. This departure 
from normal may be in the direction of a short life cycle to eventuate in 
premature necrosis, or in the direction of rapid growth and hyperplasia to 
produce hydatidiform mole and chorionepithelioma. 

Acknowlcdejcvicnt . — I wisli to express my gratitude to Dr. P. B. Bland for the con- 
stant interest and encouragement he has shown, and for the aid in providing materials 
and technical help to conduct these investigations. 

I am also deeply indebted to the personnel of the Laboratories of Pathology of the 
Jefferson Medical College Hospital lor their assistance, particularly the Director, Dr. 
Baxter L. Crawford, and his associate. Dr. Carl J. Bucher. 


REFERENCES 

Adair, Fred L.: Am. J. Obst. & Gynec. 6: 552-5G6, 1923. Beirlein, Karl M.: Am. 
J. Obst. & Gynec. 21 : 97-103,1931. Clemens, Edward : Ztsclir. f. Geburtsh. tt. Gynak. 
84: 758-770, 1921-1922. Dainoio, A[orris W.: J. Obst. & Gynec., Brit. Emp. 35: 693- 
724, 1928. Eden, Thomas Waits: J. Path. & Bact. 4: 266-283, 1896-1897. Fraser, 
John: Am. J. Obst. & Gynec. 6; 645-655,1923. Hitschmann, J., and Lindenthal, Otto 
Th.: Arch. f. Gynak. 69: 587-629, 1903. Karsner, Howard T.: Human Pathology, 
ed. 3, Philadelphia, 1931, J. B. Lippincott Co. Klaficn, E.: Arch. f. Gjuiak. 136: 190- 
211, 1928-1929. Eoba}c,M.S.: Am. J. Obst. & Gynec. 19 : 299-316,1930. Lochhead, 
James: Chapt. X, Foetal Nutrition: The Placenta, from The Physiology of Eeproduc- 
tion — Marshall, London, 1922, Longmans, Green and Co. MacCaUwm, W. G. : A Text- 
book of Pathology, ed. 3, Philadelphia, 1924, W. B. Saunders Co. Alontgomcry, Thad- 
dens L.: Am. J. Obst. & Gynec. 21: 157, 1931. Farks, T. J.: Am. J. Obst. & Gynec. 
21: 112-115,1931. SiddaU,B. S.: Am. J. Obst. & Gynec. 14 : 192-196,1927. Slc7nons, 
J. Alorris: J. A. M. A. 45: 1265-1268, 1915. Strachan, Gilbert I.: J. Obst. & Gynec., 
Brit. Emp. 30 : 611-642,1923. Strachan, Gilbert I.: J. Obst. & Gynec., Brit. Emp. 33 : 
262-287, 1926. Teacher, J. E.: J. Path. & Bact. 12: 487-506, 1907-1908. Warnehros: 
Arch. f.Gyniik. 100: 173-195,1913. Williams, J.W.: Am. J. Obst. 41 : 775-801, 1900. 
Wohlwill, Friedrich and Bode, Hans-Echard: Beitr. z. P.ath. Anat. u. z. Allg. Path. 
85: 409-512, 1930. 

1930 Chestnut Street. 


ABSTRACT OF DISCUSSION 

DR. FRANKLIN L. PAYNE. — It was interesting to look up at the Philadelphia 
Lying-in Hospital records of these patients who had been in labor over twelve hours 
with ruptured membranes. During the last eighteen months, of 3541 deliveries, 44 such 
cases were found. There were four fetal deaths: (1) prolapsed cord, (1) macerated, 
(1) hydrocephalic, (1) breach, which at autopsy showed tentorial tears. None of these 
could be ascribed to bacteremia. From these figures I believe we can deduce that the 
danger is not so much to the infant as to the mother. 

In discussing the death of one of binovular twins, Dr. Montgomery offers the sugges- 
tion of an endocrinal influence. It is difficult to conceive one endocrinal influence upon 
one growing fetus, and the reverse upon the other. As to, the innate strength of one 
ovum, and the innate weakness of the other, I cannot conceive of two ova cast off about 
the same time possessing such a difference in vitality. I prefer to look upon the death 
of the second of the twins as the result of some decidual change, some lack of nutrition 
from the maternal side, or possibly of undue pressure caused by the other growing fetus 
and placenta. 

DR. MONTGOMERY (concluding). — In reply to Dr. Payne, I can only say that an 
estimation of the hereditary factors at play in embryonic growth must include a consid- 
eration of not only the chromosome elements which are derived from the ovum, but also 
those which are derived from the spermatozoon. It is not une.xpeeted that differences 
ill growth activity of fertilized ova may manifest themselves in early embryonic life in 



335 


caky: developmental, and functional deficiencies 


the same fashion that differences in health and resistance may he manifested in child- 
hood and in maturity. _ 

I have in mind a patient Avhom I recently attended in her sixth pregnancj . ^ive pic- 
vious pregnancies hy her first husband had resulted in either miscarriage, stillbirth, or 
neonatal death. Her first husband was tuberculous. While the tuberculosis itself may 
have played no part in the actual heredity of the fertilized ovum, nevertheless, the sixth 
pregnancy, which was by a second husband, was comparatively normal and resulted in 


a normal living baby. _ _ 

The evidence which has been presented in the course of this paper is by no moans ade- 
quate proof of the influence of hereditary factors upon the growth activity of the 
chorionic epithelium, but certainly it has a significance which must be given thoughtful 


consideration. 


A CLINICAL STUDY OF 100 CASES OP DEVELOPMENTAL AND 
FUNCTIONAL DEFICIENCIES IN THE FEMALE WITH 
ANALYSIS OP TREATMENT AND RESULTS* 


W. H. Cary, M.D., New York, N. Y. 


D uring tMs epic of gynecologic progress wlien those engaged in ani- 
mal experimentation are dominating the literature with highly im- 
portant contributions bearing upon the influence of the endocrines in 
reproductive development and function, it seems fitting to present a 
purely clinical analysis of the sequelae of underdevelopment encountered 
in private patients presenting a condition of sterilit 3 ’’, in an effort to de- 
termine what relation these defi.ciencies hear to hnman fertility and to 
consider the susceptibility of these eases to successful treatment. 

To this end I am presenting a detailed stndy of a complete series of 
100 problems in which structural and functional deficiencies of probable 
hj^pogonadic origin have been encountered in the female as a chief or 
concomitant etiologic factor. Eacli of these ease histories has been itemized 
under 18 headings which include a classification of the general physical 
type (femininity), their health during adolescence (puberty), tlieir past 
and piesent menstrual history, a notation of all anatomical abnormalities 
commonly attributed to underdevelopment, a history of their response to 
sexual stimuli, a record of concomitant causes of sterility (major in several 
instances), the method of treatment pursued, tlie results obtained as to 
pregnancy, and many miscellaneous items which bear an interesting re- 
lation to this subject. 


The parallel tabulation of anatomical and functional phenomena seems 
warranted by their frequent association on the work-sheets (58 per cent) , 
hut It is appreciated that the former are static and factual while the latter 
are dynamic and variable and that a common causative factor is still hypo- 
thetical. As I had no thesis to prove, the statistics were accumulated with- 
out conscious prejudice or bias. The entries were made as noted on the 
Mtos and when completed the totals were computed. A deep interest 


•Read at a meeting of the New York Obstetrical 


Society, May li, 1932. 



336 


AJIERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


in this subject stiranlated especially conscientious study. Except in cases 
referred for consultation or out-of-town patients with limited time, the 
final entries represent the results of repeated studies and when in doubt 
as to any item a negative notation was made, for it is accepted that sta- 
tistical presentation of unreliable material is more dangerous than the 
application of balanced judgment to material withput statistical analysis. 
A small percentage of error in the findings is unavoidable owing to the 
fact that 16 per cent of these patients had been operated upon before con- 
sulting the uTiter, two lia-^ung had laparotomies and 13 others ha’^ung 
undergone a total of 16 minor operations. 

In this general group studj^ essentially preliminary in character, ex- 
tensive and at this time impractical charts would be required to correlate 
the items appearing under individual headings. Some of the accompany- 
ing charts have the weakness of most statistical tables in that they are 
quantitative rather than qualitative. It is assumed that the reader can 
and will make his own deductions from the material presented. Certain 
conclusions which are not entirely obvious by the tabulation but seemingly 
justified by clinical experience and a knowledge of the intensity as well 
as the frequenc 3 ^ of potential factoi's will, however, be mentioned. 

GENERAL CONCLUSIONS 

The structural and functional anomalies which are listed constitute the 
major causes or concomitant phenomena in approximately’’ 24 per cent of 
the sterility’’ eases encountered in general gynecologic practice and in more 
than half of the patients Avho now reach the special worker in this field. 
Clinical obseiwation indicates that no common anatomical deformity such 
as anteflexion or hyqioplasia of the uterus bears any^ constant causative 
relation to failure of conception. The extent of the lesion is of much im- 
portance. Varying degrees of hyq^oplasia were recorded in 60 per cent of 
the successful cases, and uterine flexions and displacements of the so-called 
congenital type were noted in 48 per cent. Neither do mensti’ual defi- 
ciencies, alone or in conjunction with hypoplasias, present a reliable index 
to defective o^dgenesis, and the Avork of Hartman, Corner, NoA’ak and 
others has demonstrated in higher primates a clinical impression long en- 
tertained by’’ me that menstruation is not an inA’ariable proof of normal 
o-vulation. Academically^, such factors ma.y’^ be interpreted as features of a 
sy^mptom complex. In sterility’’ Avork, hoAvever, each factor must be con- 
sidered separately in a complete diagnostic study which, by^ direct demon- 
stration or by exclusion, appraises its etiologic significance and thus points 
the way to logical treatment. The analy’’sis shows that successful results 
may be obtained in many^ cases Avith marked menstrual deficiencies, if we 
do not permit our attention to be so focused upon assumed OA’arian dy’^s- 
function as to neglect the study and treatment of other potential factors. 
Some degree of menstrual deficiency’’ was reported in 70 per cent of the 
patients Avho became pregnant after treatment and in 50 per cent of the 



3S7 


oaky: developmental and eunctional deeiciencies 

successful cases both fuuctioual and anatomical defects Mere tabulated. 
We must face the fact, imwever, that retardation of sexual developmen , 

ivbether resulting from adverse conditions of early ^ ^ 

snoudiug to fixed laws of heredity, may ao involve the gonads of ceitai 
individuals as to forever arrest their seed-producing function This con- 
dition Mhieh is not demonstrable in the female and can he inferred only 
by excluding other knoivn barriers to fertility, doubtless accounts for some 
of our failures in the underdevelopment group. Franld states, m the 
summary of his ovarian hormone studies that the findings do not ofier an 

accurate guide to prognosis in st erility . 

Experience would suggest that many of these patients produce normal 
ova at infrequent intervals and therefore marital relations with a husband 
of vigorous fertility constitutes an important factor in prognosis. In this 
group of problems it is most important to recognize the lesser degrees of 
seminal defects.'-' The term “fertility ’’like “health” isarelative one and 
attempts to increase the impregnating power of the male specimen was 
considered an important supplementary procedure in 10 cases of this 
series. Finer measuresf of sperm cell energy are needed. 

The statistics as to results (Table IV) show that many cases in this 
series ('39.T per cent) when managed in accordance with the above prin- 
ciples presented an opportunity for successful treatment. . 


GLANDtJDAU THERAEY 

While glandular products were used as supplementary treatment in 13 
of these cases they are not regarded as a major factor in success in a single 
instance. This observation may indicate a lack of knowledge in the use of 
remedies highly regarded by many gynecologists" or a bias in the confused 
problems of interpretation. 

For example, in a case which came to me several weeks subsequent to careful study 
iu cxceUeut hands, the -wife was found to have a congenitally shortened vagina and 
a hypoplastic uterus in unyielding hut symptomless retroversion-flexion. The tubes 
•were patent at normal pressure. Prompt semen loss rvith defective sperm migration 
was demonstrated. The husband, though of active mentality, was sluggish pliysieally 
and sexually. His metabolism, as well as the wife's, was moderately defleient and the 
semen while rated potentially fecundating was entered as subnormal, as were also his 
secondary sexual attributes. He neglected all treatment except for continuous thyroid 
.administration. The wife, who had already undergone two minor operations and had 
now been urged to have a laparotomy was sustained in her refusal of the latter by both 
the family pliysician and myself. In appreciative confirmation of the diagnostic at- 
titude, this woman recently reported that pregnancy had occurred after four months' 
marital relations with a different mate. The lessons taught include the realization 
tat had the operation been done and pregnancy occurred while the first husband eon- 
timied under medical care an accurate conclusion as to the most important factor in 
successful treatment would have been difficult. 


obsl?vations®a?e^bei?g this field, and their 

ana others, jfacnch and Bolt: & C»m wld! IT : p° 297(T93L®'‘‘‘"^^ Moench 



338 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


Chief roliauee has been placed on thyroid substance, and though men- 
strual irregularities have thus been improved it has not, in my opinion, 
brought success in any case of this series. Limited experience "with 
metabolism studies has given the reporter reason to believe that the find- 
ings are varied by many extraneous influences, that when carefully made 
the.v are sometimes in conflict Avith the clinical data, and that the latter 
should not be too readily subordinated. While I am Avatehing AAuth admira- 
tion and interest the Avork being done in ovarian and pituitary hormone de- 
terminations, this study has not as yet been recommended to unfertile pa- 
tients, because tliose aa’Iio have contributed most to our scientific informa- 
tion in this field, liaA’^e also demonstrated the difficulties AAflieh still obtain 
in applying this knoAvledge to tlie clinical management of sterility. 





ATer&go of eontncoptloa 


Fig. 1. — Average duration of marriage and unfertility. 
GENERAL DATA 


The aA’^erage age of these patients AAdien they consulted me Avas 28.7 years 
CPig. 1 ) . The ages Amried from a minimum of tA\’enty-three to thirty-eight 
years and one success was obtained at this maximum age. Any conclusion 
as to the relation of age to prognosis is impossible at this time. The aA’^erage 
duration of marriage Avas four and one-half j^ears, ghung an aA'erage mar- 
riage age of approximately tAventy-four jQars. Contraception had been 
practiced for an aA^erage period of nine months, the term of “pregnancy 
try, ’ ’ therefore, being three and seA’^en-tenths years. Sterility Avas primary 
in 91 couples (Fig. 2), while secondary sterility Avas due to abortion 
(probably spontaneous) in 6 instances. In one of the remaining cases 
hyperinA'^olntion and prolonged amenorrhea had folloAved the first preg- 
nancy, in another case the first pregnancy had been terminated by 
cesarean section for acute hyperthyroidism, the latter symptoms persisting 
moderatel5’ in spite of thyroid surgery and Avere complicated by uterine 
atrophy and menstrual irregularity’-; and in the final parous case, one- 




CARY; DEVELOPAIENTAIj AND RUNCa'ION'AIi DEFICIENCIES 


339 


child sterilitj" with functional deficiencies was also reported in the two 
preceding generations. 

PHYSICAI) TYPES 

As data relative to interrelation of the gonads with other glands and the 
clinical concepts of their dysfunction are being constantly revised, these 
patients were classified simply with reference to marked variations from 
our impression of the normal feminine type ; groups familiar to any ob- 
servant physician. Overweight is recorded in 12 instances, not the obesity 
often seen in careless clinical patients but devotees of the mode wlio in spite 
of normal inheritance and intelligent effort gained weight rapidly at 
pnberty, after marriage, or coincident with menstrual deficiencies. In 



2 cases a diagnosis of Froehlich’s syndrome was made. There were 20 
entries under the immature type. Typical of the more pronounced type 
was one patient, aged twenty-seven years, who although she graduated 
trom college four years previously had the mien of a freshman There 
V ere a gracde body, flat breasts and a narrow pelvis, and although teeming 
vith feimnme artifices, she reported frigidity and long-continued dys^ 

ueie collected Only two patients were classed as masculine In these 
ses general physical manifestations of tlie condition were obvious In 

tae Ma.., sue. aasea a« do'ub.te pituit.; Tne 



340 


A.7>IERICAN JOURNAli OP OBSTETRICS AND GYIIECOLOQY 


brilliant girl in this group, however, had an upper spine deformity with 
some variation in the size of the hands and other symptoms which a neurol- 
ogist attributed to a temporary hemiplegia in early infancy due to un- 
knoivn injury. As her physical abnormalities were not inherited, her 


Ateorc&l 


of 

39 


20 


12 


ItanAturt 

OTor:rel£lvt 
Stunted, growth 3 

Froehltch ayndrooe 2 

llAscullne £ 

SotbaI fftalni&e 61 


Fig. 3. — Physical types varying- from normal feminine. 


habitual amenorrhea, anteflexion, and lateral uterine displacement (which 
corresponded to the early paralysis) were treated, pregnancy followed, a 
51/2-pouud otherwise normal baby was delivered at term and is now thriv- 
ing. The other patients of this group reported failure to grow after a 
definite time in adolescence, one attributing the condition to the shock 



Pig. 4. — Abnormal conditions ol early adolescence. 


of her mother’s death and the heai^’’ responsibilities she assumed as the 
oldest child, while the other patient accepted the condition as a family 
trait. In the former case successful results were obtained but the latter 
who came at the age of thirty-ttvo years, with marked hypoplasias, was 
less fortunate. 



CART : DEVELOPMENTAL AND FUNCTIONAL DEFICIENCIES oi-*- 

HEALTH DURING ADOLESCENCE 

The histories of certain intelligent patients have foensed my attention 
■upon the possible inflnence that disease (aente or chronic), major opera- 
tions, hard work, and excessive athletics during early adolescence may 
bear to sexual drag or underdevelopment. The adolescent history rela- 
tive to these factors has been secured in 89 cases (Fig. 4) . Because the fig- 
ures are possibly without value, unless compared with a normally fertile 
series, they are given without comment except to state that the percentage 
of typhoid (5.5 per cent) seems high and that in view of the retardation 
of skeletal groAvth and mental development which is knoAvn to occur in 
some instances of severe disease in adolescence such a history should be 



6 


Scanty 
czcGaaiTe 
77 caaea 

Pi&. 5. — Summary of 



15 cases 

menstrual irregularities. 


covered in all sterility problems. Experience with a few adolescent girls 
warrants a further study of the relation that excessive competitive ath- 
letics in girlhood bear to their pelvic development. 


MJbNSTRUAIi IRREGULARITIES 

Menstruation began in these 100 patients at an average age ol 13.6 yean 

tbri ^ ojiset was as late as eighteen in three cases ivhile in one 
three and eleven patients it began at the seventeenth, sixteenth and fU 

? r on “ 

aennitely delayed. In other respects Pig. 5 speaks for itself and so mnel 

fnrtire«Tt(ffll“h^n«^^ X"' 

nm oe uncieitaken. Dysmenorrhea is confirmed a! 





342 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


a very frequent symptom of underdevelopment and abnormal uterine 
rhythm. Menstrual deficiency far exceeds excessive flow as a functional 
disorder in sterility problems and the latter is found to be more difficult to 
manage. Amenorrhea is tabulated as transient when reported during 
adolescence only or at rare occasions thereafter, and as habitual when ex- 
perienced frequently throughout sexual life. In at least two patients of 
the latter type pregnancy occurred during a pei’iod of functional amenor- 
rhea. In one patient of the menorrhagia group, endometriosis was encoun- 
tered, while in another patient, thirty-two years old, in whom menorrhagia 
alternated with amenorrhea, marked hypeiqilasia of the endometrium ivas 
found and the specimen was at first reported malignant but subsequently 
termed border-line and innocent by Dr. Ewing. 

BASAL METABOLISM 

D 3 ’sfunetion of the thj’roid maj* be associated with both oligomenorrhea 
and menorrhagia, and h^qiertrophj’- (with or withont toxemia), pelvic 
hjqioplasias, scanty periods and childlessness have been found coexistent 
in a few patients who are not included in this series because the sterility 
problem was not the major complaint. In 18 cases the clinical sj’^mptoms 
were sufficiently suspicious to suggest metabolism studies (Table I) . The 
average group findings indicate little. Individual results showing 6 cases 
Avith abnormallj^ deficient and 3 ivith abnormallj’^ high metabolism records, 


Table I. JlETiVBoiiiSM Findings in IS Cases 


1 

Minus 

11 cases 

Average 10 % - 

Maximum 27 % 

Plus 

7 cases 

Average 13 % + 

Maximum 27 % 

Abnormally high 3 




Abnormally reduced 6 





with one success in the former and 2 in the latter group, did little to dis- 
sipate mj^ perplexity as to what direct relation, if anjq the tliju'Did bears to 
unfertility. These patients received a trial of medical treatment, gyne- 
cologic procedures having been concomitant or deferred as indicated by 
the correlation of all potential factors. The maximum and minimum 
finding ivere each 27 per cent. Mj’- limited experience would seem to indi- 
cate that the clinical symptoms of the overacting and underacting thyroid 
are sometimes verj^ similar and in such cases laboratory studj’- may be 
helpful. It is onty just to saj^ that in an occasional case tested during the 
same Aveek bj’- tA\’o different laboratories, AAude variations have been 
reported. 

ANATOMICAL ABNORMALITIES 

Probablj- the majority of gjuiecologists entertain some doubt as to 
AAdietlier structural abnormalities of the female reproduettye tract com- 



CAKY ; DEVELOPIiIENTAli AND EUNGTIONAL DEFICIENCIES 


343 


monlj^ attributed to sexual drag actually have such an origin. Either a 
pro or con opinion is difficult to sustain, but a correlation of the items 
across the work-sheets seems to present affirmative evidence. Any one or 
any combination of the several lesions described may be encountered in the 
individual patient. Hypoplasia of the external genitalia is, of itself, prob- 
ably of little significance in fertility, nor is it alone used as a basis for ease 
selection, but in this series smallness of the vulva does seem to be fre- 
quentty related to lack of emotional development. Shallowness of the va- 
gina, annular constriction, shortening of the anterior wall and septa have 


HYPOPUSIA 



St«noeli Pvuvo- 
tate 


UTEHIHE DSF05M1TIBS 


SfttTOTereion 24 



'Karked complicating eibotos Pai>tlal Taglnal septum 2 

Reetnast vaginal septun 1 

UteruB Mcornls J 

Uterus euliseptua J 


Cenerftlly contracted pair la 1 
Breasts suhnoraal in else In 12 out of 57 cases noted, 

Fig. 6, Summary of hypoplasias and structural deficiencies. 


been included under vaginal underdevelopment. Experience causes me 
to place greater empliasis on cervical lesions as stigmas of underdevelop- 
ment and causes of low fertility than upon the lesser degrees of fundal 
iJToplasia. Under the "cervical group” the total number of these cases 
with stenosis and a punctiform external os has been noted. The slender 
conical cervix is also included under "hypoplasia,” and when its length is 
mkedly increased with corresponding hypoplasia of the fundus, the 
p ognosis IS less hopeful. The diagnosis of hypoplasia of the fundus was 

e«slul e™ f 1 T T by sound and sue- 

cessti l lesults occurred in three of these cases. Slenderness i>. 



344 


A.MERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


gists ; that is, the association of these findings -with shortening of the pelvic 
fascia and other evidences of deferred or incomplete sexual development 
(Fig. 6). 

The diagnosis of uterus subseptus is open to question, but it represented 
my best impression gained during digital removal of retained secundines 
after misearriage. Pregnancy occurred after months of general building- 
up of this malnourished, socially ambitious -woman -who gave the history, 
already mentioned, of three generations of amenorrhea and one-child 
sterility. The bicornate uterus was revealed bj’- instillation and x-ray. 

The growth of the breasts is generall 3 '^ regarded as a secondaiy sex char- 
acteristic, but bej’-ond recording the percentage of cases in which flat or 
small breasts were noted, no further statement will be made at this time. 



Pig. 7. — Approximate tabulation of sexual histories. 


Vicarious bleeding from the breasts occurred in one case with habitual 
amenorrhea and hypoplasia. 

SEXUAL INTEREST 

The motives which may determine one ’s selection of a mate are so vari- 
able, and the fears, fixations, and inhibitions of both conscious and sub- 
conscious origin which maj”^ affect sexual response, are so numerous, that I 
suspect that a patient even tvith sincere intent and analytical guidance, 
is frequentlj’’ unable to appraise her sexual reactions or potentialities. 
Fig. 7 represents my best effort of evaluation within the further limitations 
imposed b 3 ’’ g 3 aieeologic practice. Patients who report a persistent indif- 
ference to normal emotions of coitus in which male responsibility seems to 
be eliminated are classified as frigid. The 10 per cent of frigidity in this 
veiy small series closely coincides with the percentage reported by Dickin- 



CAKT: DETOLOPMENTAIi AND 


FDNCTIONAI/ DBFICIENOrES 


345 


son ana Beam in "A Thousand Marriages.” This wnld seem to si^ty 
SLi«y is no more eommon in the seleeted cases ol te s udy than 
in a heLogeneons group. Under the “subnormal heading 
included eases in which the transference ol the erogenous sone has not 
occurred, those in whom sexual abstinence may be definitely sustained li it 
equanimity and patients who without extrinsic explanation rarely expen- 

ence au orgasm. 

rnNOOAllTANT FACTORS 


The eoncomitaDt factors involved in failui’e of fertility in this gronp 
study are itemized on the work-sheets but will not be discussed at this 
time. Such a tabulation would be of interest chiefly in an analysis of the 



failures, a study now under consideration. In many cases, as will appear 
below, these coincident lesions assumed the major role in etiology and in 
determining management and in several instances eontraindicated gyne- 
cologic treatment, 

UNTREATED CASES 

In 40 cases of this series {Fig. 8 and Table II) sterility was not treated 
by me for reasons which are sufficiently explained in Table II as to need 
but little further elaboration. Treatment was not undertaken in 14 prob- 
lems, oniug to conditions in the male. Complete absence of sperm cells in 
two specimen examinations was found in 8 cases. In 5 additional cases in 
which marked semen deficiency was revealed, the husbands, with or with- 
out urologie consultation, declined to follow recommendations. Impotence 
m the form of habitual premature ejaculation was discovered in one pa- 



346 


AJIERICAISr JOURXAL OP OBSTETRICS AND GYNECOLOGY 


tient, and the unsophisticated wife had been subjected to much useless 
treatment on the misleading evidence of a condom specimen. 

Among the untreated group of cases due to conditions in the female 
were 4 patients in whom the tubes seemed to be occluded. More than 
half of the patients with normal tube patency had received one or more 
patency tests before consulting me, as many as six insufflations being re- 
poi’ted by one patient. Strangely enough, many of these patients were still 
ignorant as to the results of the tests or as to the pressure at which patency 


Table II. Reasons for Not Treating 40 Cases 


CoJulitioB of the jnnie 
Azoospeniiia 

Higlih' deficient innle 
Mnio impotence 

8 

,*> 

1 1 

i 

14 cases 

Condition of tlie feniolc 


7 cases 

Occluded tubes 

^ 1 


Acute gonorrlica 

1 


Tuberculosis 

1 


Hypertliyroidisni 

1 

! _ ... 

Other reasons 


1.0 cases 

Declined treatment 

10 


Consultation eases t 

0 



was effected, and many of them submitted to a repetition of the procedure 
thinking it was of major therapeutic value. These women might have been 
saved the I'isk and traumatism of repeated tube tests if the first investi- 
gator had submitted an intelligent statement to the patient. 

Investigation was contraindicated in one patient owing to evidence of 
active gonorrhea, and the risk of motherhood seemed sufficient in one pa- 
tient with tuberculosis, and in another with marked hyperthyroidism to 
justify the omission of treatment. 

Fear, economical stringency and I’eluctant cooperation caused treat- 
ment to be declined, deferred or transferred to another physician in ten 
instances, while 9 other patients came or were referred for diagnostic studj’^ 
only. ( 

TREATMENT AND RESULTS 

Tabulating cases under any one form of treatment is extremely difficult 
for tonic, dietary (Vitamin), hygienic, and specific forms of medical treat- 
ment were frequently carried out in conjunction with local procedures, 
and in not a few cases, the husband and wife were under treatment simul- 
taneously. I have attempted to classify my cases under what seems the 
most important gynecologic pi’ocedure (Tables III and IV). As the basis 
of group selection and study was gynecologic, the treatment of the husband 
is entered as supijlementary and was carried out in 10 eases, in some of 
which it may have possibly constituted the most important item. As 







347 


CAKY : developmental AND FUNCTIONAL DEFICIENCIES 


glandular therapy u^as not continued aa the sole method of 
any successful ease, it is also tabulated as supplementary m 13 'ustauces 
and its curative value in relieving sterility was not impressive. Dud j the 
“Supplementary” heading might have been included two eases ivi h ob- 
vious ovarian dehciency, in which, after all other methods had faded, a 
trial of x-ray stimulation was accepted by tbe patients after receiving a 
frank statement of its uncertainties. Results were disappointing but it is 
only fair to state that tbe uterus was markedly liypoplastie in one case, and 


Table III. Major Gynecologic Procedures With Results in 60 Cases 

, CHIEF TREATMENT 

CASES TREATED 

PREGNANT 

General: Piet, tonic, etc. 

7 

2 

Local 

2 


Dilatation and curettage 

6 

t> 

Dilatation and curettage and radium* 

2 

9 

Dilatation and stem 

15 

Dilatation (office) 

5 

4 

i 1 

Dilatation and cautery 

2 

Relief cervical viscosity 


2 

Longer wait 

7 

G 

Pessary 

7 1 

2 

Stem (office) 

1 

1 

Premarital dilatation and excision of vaginal 



septumt 

1 

1 

Salpingostomy 

2 



60 

31 

S0PPLEMENTARY TREATMENT 



Endocrine 

13 


Improvement male specimen 

10 


X-ray stimulation 

2 



♦One very early malignancy and one approaching borderline malignancy. 
tPreceded by trial marriage. 


a subnormal male specimen resisted all efforts of improvement in the other 
problem. Injection of this specimen, after x-ray treatment of the wife, 
was accepted by the patient and constituted the final effort to date. One 
unsuccessful dilatation and stem case was subsequently reported pregnant 
after x-ray stimulation under the care of another physician. 

In recording the results of treatment the reporter has attempted to 
“lean backwards ’ ’ in accuracy and honestsL I have charged myself with 
all cases in which treatment was instituted, accepting full responsibility if 
the male diagnosis was inaccurate or his improvement disappointing. 
Some patients are included as failures for whom the possibilities of suc- 
cessful treatment are not exhausted. Two cases have been entered as 
failures in which the necessity of radium administration after curetting 
rendered success practically hopeless, in fact, undesirable. In one of these 
patients, thirty-four years old, an extremely early, symptomless, and 









348 


AMERICAN- JOURNAL OP OBSTETRICS AND GYNECOLOGY 


therefore unexpected carcinoma of the fundus ivas discovered. Curet- 
tage was not planned in this case of hjTier involution and stenosis until the 
routine procedure of damp biopsy of the endometrium brought away a 
suspicious section. In the second ease, already referred to, hyperplasia 
had advanced to a suspicious degree.' 


T.\ble I-y. Absolute and Corrected Percentages of Success 


Based, on total cases seen 

31.0% 

Deducting consultation cases and patients Avho declined 
treatment or were advised against the risk of motherhood 

39.7% 

Deducting also hopeless male deficiency or untreated semen 
abnormalities 

48.4% 

Deducting also cases of closed tubes 

51.7% 


On the other hand, cases of known miscarriage have not been subtracted, 
the reporter feeling that this is no more evidence of failure of sterility 
treatment than the loss of a fetus at a more advanced date owing to 
Ijlacenta previa or other obstetric accidents. Six couples who, after pre- 
liminary study and genei’al instructions, were advised to defer specific 
treatment, and the wives subsequently reported pregnant, are credited as 
successes, this constituting in my opinion the most efficient type of service. 
Such eases finalty requiring ti’eatment were of course othendse classified 
and the one who disappeared from cai-e was included as a faihu’e. 

Dilaiaiion and Stem . — The largest number of cases (15) is entered 
under the heading of “Dilatation and Stem Pessary.” The solid glass 
Baldivin stem was used in all cases, being left in situ, unless disturbing, 
from four to seven weeks. The large number of successes (60 per cent) 
occurring in this small group of cases is attributed to great care in 
the selection of patients and special effort in technic involving the anchor- 
ing of the stem entirely within the external os by a deep, snug and inelastic 
suture. The loose suturing previousty advocated has been abandoned be- 
cause mobilitj^ with partial expulsion of the stem increases the drag upon 
the sutures. The stem is omitted when curettage is required. Any suspi- 
cion of past or present infection in the husband or wife is considered an ab- 
solute contraindication, and as a further prophylactic measure against in- 
fection, intercourse is interdicted Avhile the stem is in place, mild antiseptic 
douches are ordered tivice Aveekly and inspection is made at ten-daj’- inter- 
vals. I am not unaivare of the adverse criticism this method of treatment 
wiU evoke from many gjuiecologists. The controA'^ersial features Avill not 
be discussed beyond saying that objection to the intrauterine stem is often 
based on negative theoretical grounds or results from improper clioiee of 
stem, or selection of patients. Many gjmecologists of highest repute and 


CARY: DEVELOPjMENTAL, AND EENCTIONAE DEFICIENCIES 


349 


.videst experience are ivarm advocates of its use in certain cases of sterility 
and dysmenorrhea although the modns operandi by ivhich residts aie o - 
tained may not be definitely understood. Observance of a clinical phe- 
nomenon often precedes the explanatory formula. Suffice it to say that in 
addition to the purely mechanical factors ivhich it may correct there are 
some evidences, by animal experimentation, that a reflex stimulation may 
occur. Parkes^' states that mechanical irritation of the cervix stimulates 
the ovary and quotes the ivork of Long and Evans^ indicating that this ef- 
fect is exerted indirectly through the anterior pituitary and Corner has 
demonstrated that under certain conditions of glandular activity any 
foreign body in the uterus causes decidual growth. The patient entered 
under “Office Stem Treatment” was twenty-seven years old and had sus- 
tained hyperiuvolution of the uterus (2t/^ inch cavity) following her first 
delivery three years before. She had almost given up hope of becoming 
pregnant, consulting me principally for an amenorrhea of two years’ 
standing with iveight gain and other sjunptoms of early menopause. After 
stimulating a uterine flow of three days’ duration, the stem was tempo- 
rarily replaced at four-iveek intervals over a period of four months, with 
fairly regular uterine bleeding. The stem was then discontinued and en- 
docrine treatment, which the patient had taken unsuccessfully for the pre- 
vious year, was again prescribed and a successful pregnancy began two 
months subsequent. One of the successful cases entered under the “Dila- 
tation and Stem” group was subjected to laparotomy for retroversion at 
the time the stem was inserted, contrary to my usual procedure. Radical 
intervention was requested because the patient planned to soon leave for 
the Par East where further study and pessary control would be imprac- 
ticable. Laparotomy has been avoided whenever possible. Invasion of 
the peritoneal cavity occurred in but two other cases. In one of these, 
salpingostomy is entered as the major procedure. This patient with cer- 
vical stenosis and a hypoplastic anteflexed uterus ivas also found to have 
occluded tubes attributed to acute appendicitis and operation soon after 
marriage. Right oophorectomy was also reported but owing to the death 
of the surgeon and the absence of data in a general hospital of a large city 
no confirmation was obtainable. Against advice and the most discourag- 
ing prognosis the patient urged operative interference at which time it was 
discovered that the left tube had also been sacrificed and the right tube 
damaged. 

Paginal Pessai y.—ln i cases the use of the vaginal pessary was deemed 
le ma 3 or gjmecologic procedure. The important indications for the pes- 
sary are a shortening of the vagina with a marked anterior displacement 

coital stnil?’ vetroversion-flexion, providing careful post- 

deml of semen loss and deficient spermigration. The 

d pth of the vagma may be definitely increased by this method of treat 

me, ctao„3, b, H.e Ia.g J pessaritrat 1 cat 



350 


AMERICAN JOURNAL OP OBSTETRICS AND QYNECOLOGT’ 


progresses. 'Women frequently report a prompt modification of their 
sexual experience. In 2 cases of this series in which occlusion of the tubes 
was also eneountered, normal patency was found, not immediately but two 
months subsequent to reposition and support of the uterus. This result is 
attributed to the subsidence of a coexisting edema, a possibility that 
should be entei’tained in cases of unexplained tubal obstruction complicat- 
ing replaceable retroversion. 

If the retroversion resists efforts of reposition made with the patient 
under anesthetic or after trials of replacement at the office with the patient 
in the knee-chest and tenaculum traction on the cervix, the problem as- 
sumes of course a much more formidable character. 

Other Factors. — The 4 successful eases tabulated under “Office Dilata- 
tion” were patients in whom pregnancy occurred so promptly after com- 
pletion of the diagnostic routine that the result seemed attributable to 
anatomical or secretory changes in the cervix following the passage of a 
sound, suction or insufflation cannula, etc. It is possible that pregnancy 
maj’’ have occurred incidental to the studj’- ; a small margin of error that 
must be accepted in most statistical studies. Patients whose blood exami- 
nations showed anemia and were obviously undernourished or nervously 
exhausted have received appropriate medical treatment. Statistics from 
tubercular colonies and observers in busy obstetric services will suggest 
that attention to these details may be a contributing but certainly not an 
essential factor in increasing fertility. The diet of patients has been 
scrutinized but not to the point of caloi’ic tables. The greater percentage 
of these patients were highly intelligent women Avith considerable knoAvl- 
edge in selecting well-balanced menus for the family. In a feAV instances 
a nitrogenous intake was increased. Cod liver oil of other dietary in- 
creases favoring Aveight gain Avere often declined bj'’ patients unless they 
were definitely malnourished. I admit a lack of knowledge and experience 
in the use of vitamins. Because Vitamin E is largelj’- omitted from one’s 
diet and seems theoretically indicated an inA'estigation is noAV being made 
as to the practicability of a concentrate. 

In conclusion, it maj’- be stated, that these cases haA^e been managed first, 
and most important, by meticulous diagnostic study to appraise in the in- 
dividual case the significance of functional deficiencies and the role played 
by developmental defects in the prevention of fertility ; and, secondly, by 
the correction of causative factors according to sound principles of med- 
ical practice and Avell-established gjmecologic procedures, methods AAliich 
may be improA^ed or superseded tomoi’row by the discoveries of our 
biochemists. 

REFERENCES 

Frank, F. T.: The Ovarian Hormone, Springfield, 111., 1929, Charles C. Thomas. 
Stein and Leventhal: J. A. M. A. 98: 621, 1932. Parkes, A. S.: The Internal Secre- 
tions of the Ovary, 1929, Longmans, Green & Co., p. 171. Long and Evans : The Oestrus 
Cj’cle in the Eat and Associated Phenomena, Memoirs ITniv. Calif. No. 6, 1922. 

57 West Fifty-Seventh Street. 



OVAEIAN STRUMA; A MORPHOLOGIC, PHARMACOLOGIC, AND 
BIOLOGIC EXMIINATION'' 

Alfred Plaut, M.D., New York City, N. Y. 

(From the Beth Israel Hospital) 

S INCE at the beginning of this century, Ludwig Pick^ insisted upon the 
thyroid character of ovarian struma, the term “ovarian struma” des- 
ignates a definite type of ovarian tumor. Ovarian struma is a teratom- 
atous ovarian tumor in which large amounts of typical thyroid tissue are 
present. The term therefore does not apply to the small areas of thyroid 
tissue Avhich are found in about one-third of all dermoid cysts. 

About 70 case reports of ovarian struma exist in European and Amer- 
ican literature.^' " Our purpose is not to increase the number of the ease 
reports, but rather to settle a long-standing dispute. Many have stated 
that a tumor may resemble thyroid tissue very closely and nevertheless it 
may not be thyroid tissue functionally. Such a question concerning most 
organs cannot be answered. In the case of the thyroid gland, however, we 
fortunately have chemical, pharmacologic and biologic methods to prove 
the thyroid character of a given tissue. To anticipate our result, we can 
say that thyroid tissue in ovarian struma chemically, pharmacologically 
and biologicaRy behaves like thyroid tissue. 

The three cases we had the opportunity of examining were briefly the 
following. 


Case 1. — 'Scotch housewife, forty-seven years old, married twenty-four years, one 
adult child, one abortion three years ago. Menopause began a year before admission 
to the Woman’s Hospital. 

She came to the hospital because for five months she had a pain in the left side of 
the abdomen. A mass could be felt in the left side. The provisional diagnosis rested be- 
tween ovarian tumor and endometriosis. 

At operation an ovarian tumor the size of an orange was found behind the uterus to 
the left. Uterus and right appendages were normal. Tlie tumor was apparently cystic 
but heavy. One portion of the surface was suggestive of endometriosis. The pathol- 
ogist, on gross examination in the operating room, declared the tumor malignant. 
Therefore the body of uterus and the right appendages were removed. The cervical 
stump received some prohpliylactic radiation afterwards. The patient was well three 
years after operation. 


Case 2.— Roumanian housewife, thirty-five years old. She has two living children. 
Twelve years before admission to Beth Israel Hospital, a mass in the abdomen was 
noticed and the patient was advised by the doctor to have it removed. The mass grew 
larger padually, not showing any changes during the pregnancies. Every summer 
the patient had vomiting spells with considerable nausea. This condition became worse 
and caused tlie patient to ask for operation. 

At operation a large, multilocular cyst of the left ovary was found. There also was 
a arge, cystic mass in the right ovary, the uterus was slightly enlarged but normal in 

SS mtTent T'" appendages were removed. 

^ ^ ^ 8°°^ ^'calth two and a half years after operation. 


•Presented by invitation before the Xew York Obstetrical Society, Way 10. 1932 

351 



352 


AJIEUICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


Case S.—Russian housewife, fifty-five years old. She has seven living children. 
She entered into menopause five years ago. Her abdomen had always been large, but 
it became much larger in the weeks before admission (to Beth Moses Hospital*). She 
had frequency of urination and mild, indefinite pains. On physical examination the 



Fig. 1. — Case 3. Gro.ss specimen of ovarian struma. The photograph was taken from 
a museum specimen after some shrinking had taken place. The dark central portion 
consists of thyroid tissue witli compact bone. The whole specimen, even the wall of the 
large uncharacteristic cysts, is tliyroid tl.ssue also. 



Fig. 2. — Case 1. Ovarian struma. Gross specimen. Photograph taken from a w ater- 
color. The area which is the shape of a flgure-of-eight near tk® Attochment of the Iig - 
ment, is typical thyroid tissue and has a very high iodine content. The glistening loun 
masses are mucin ; the remainder is solid tumor. 


‘This specimen was given to me by the late Dr. Ivwartin. 




Pl^AUT: OVARIAN STRUJIA 

aMom... <vas f...4 Ml »« «»»«*■ -« tl.o aa.« time a large, sett, m.v.able, .et temto 
'Tlip ('linical diaEnosis was ovavian cjst. 

m"; S. s^g ,™L a, St was tsaad, tegetbev wltb a large ame.mt et 
ascitic fluid. No follow-up notes on this patient are available. 


morphology 

All three specimens have the character of ovarian teratoma. They con- 
tain different tissues, as for instance, bone, nervous tissue, mncinous 



Fiff. 3. — Case 1. Nen'ous tissue in ovarian struma. The tliyroid character is evident. 
Thyroid goiters do not contain nerves. The presence of the nervous tissue indlcfates the 
teratomatous character ot ovarian struma. 



4. Case u. Dense bone with typical thyroid tissue in the marrow spaces. The bone 
IS a sign of the teratoid character. 

glands. In all three specimens pseudomucin ivas absent, and there were no 
histologic signs of ovarian cystoma. Cystomas are very frequent in the 
ovary and very often found together with dermoid cysts. It therefore is 
not astonishing to find a cystoma and a teratoma, as for instance the 
ovarian struma, in the same ovary. This is coincidence. 

The gross specimens will not be described in detail since such descrip- 
tions are abundant in the literature. In the second and third eases almost 
the entire tumor consisted of tiumoid tissue. This is often the case in large 



354 


AjMERICAN journal op obstetrics and gynecology 


specimens (Fig. 1). It is assumed that the thyroid tissue for some un- 
known reason has grown and has destroyed the other tissues by pressure. 
In the first case there was an unnsual feature about the gross specimen ; 
namely, large, gray, solid areas, and large mucinous (not pseudo- 
mucinous) areas (Fig. 2). 

In the microscopic description also we do not intend to repeat the state- 
ments of other authors, hut we want to dwell on unusual featui’es only. 
Aside from the ordinaiy structure of colloid goiter, histologic pictures 
were encountered which are found in the thyroid gland, some of them 
frequentlj^, some rarely. Papillaiy portions are often seen in goiter, and 
epithelial bolsters with high cylindrical cells. We are accustomed to see- 
ing nerves in the teratoid dermoid cysts of the ovarj’-, but it is a striking 



Fiff. 5. — Case 1. Mucicarmine stain. Ovarian shnima. Several follicles are filled 
with thyroid colloid. It appears homogeneous. One large follicle is entirely filled with 
mucin. It appears darker and filamentous. The medium large follicle at the edge of the 
picture is mostly filled witli mucin, but its outer portions are occupied by thyroid col- 
loid. This definitely proves that the mucin is produced by tlie thyroid adenoma itself. 

picture to see thick nerves in a goiter nodule, as they were found in two of 
our specimens (Fig. 3). The same applies to the bone tissue so often en- 
countered in dermoid cysts of the ovary. In our third specimen the thy- 
roid tissue is growing in the spaces of very dense bone, filling them in the 
fashion of bone marrow (Fig. 4). 

The production of mucin deserves special consideration. In our first 
specimen mucinous glands were found. This is nothing unusual. The 
upper respiratory tract very often is represented in dermoid cysts, and 
mucinous glands similar to those of the trachea are frequently found. 
Large masses of true mucin, however, do not belong to the picture of a 
dermoid cyst of ovary. The mucus found in our first specimen probably 
does not come from the occasional mucinous glands. It is a product of the 
solid tumor which is found together with the thyroid tissue. We talk 
about true mucin only when the histochemical reaction for mucin has been 
definitely positive (mucicarmine stain). Astonishingly enough, mucin 
was found in typical thyroid follicles, and typical thyroid secretion was 



PIjAUT ; OVARIAN STRUAIA 


355 


nr a„. .™no„,a...e 

solid tumor ^vere found side by side and even intimately mixed (ri„. ). 



Fls 6.-Case 1. Thyroid tissue mucin (0>e white area), and trabecular carcinoma arc 
° Intimately mixed In tho tumor. 



Pig. 7. — Case 1. Higher magnification of the solid tumor. Trabecular and tubular 

growth. 


The character of the solid malignant tumor again points in the direction 
of young thju'oid tissue. It resembles the tubular and trabecular stnima 
of Masson,® which is found in young people chiefly (Fig. 7). The simi- 
larity of the tumor in our Case 1 with the pictures of trabecular adenoma 
of thyroid is striking. 

Prom the foregoing it is evident that ovarian struma, not only in the 
common features, but even in unusual ones, morphologically behaves like 
true thyroid tissue. 



356 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


CHEMISTRY 

The thyroid gland differs from all other organs by its high iodine con- 
tent. The iodine figures of analyses of thyroid vary. Nevertheless the 
order of magnitude ahvays is different from the figures for the iodine 
content of any other organ. This applies as well to malignant tumors, 
which, under certain conditions, may store iodine given by mouth. 

TIio literature contains few reports on the iodine content of ovarian struma. Eobert 
Meyer' in 1903 found 0.014 mg. of iodine per gram of dried ovarian struma. Neu' 



Pig. S. Fig-. 9. 


Pig. S. — Tadpoles fed with material from Case 2. Upper row, four tadpoles fed with 
ovarian struma which contained iodine. The animals have well developed hind legs, 
their body and head begin to be frog-like. Their tails are thin. Lower row, four control 
animals from the same egg ball. They have only small buds in place of the hind legs. 
Their tails are large and broad, their body and head are regular in shape. 

Pig. 9. — One tadpole fed with ovarian struma from Case 2, together with one control. 

in 1911 found 0.02 mg. Schauta® in the same year reported positive iodine findings 
■ndtliout giving figures. There are a number of negative iodine findings. Tiie authors 
have expressed different opinions as to the meaning of positive or negative iodine 
findings. 

Our three siiecimens have been examined for iodine according to the 
method of Kendall and Richardson® by onr chemist. Dr. Ella H. Pishberg. 
All analj'-ses were done repeatedly and with controls. The thyroid-like 
portion of Specimen I contains more iodine than any ovarian struma ever 
examined. The figure of 0.673 mg. of iodine is in the order of magnitude 




PIAUT; OVARIAX STRUMA 


357 


of thyroid and not of any other organ. The malignaiit portions of tlic 
same specimen contain a very small amount of iodine only. The second 
specimen contained 0,025 mg. of iodine, which is still above the range of 
any other organ. In the third specimen, on repeated analysis, no iodine 
could be found. As shown in Chart 1, fluid from the ovarian cysts, and 
malignant tumors of breast as well as of ovary were examined with the 
same technic, and were found free or nearly free of iodine. 

Thus the chemical examination proves the thyroid character of ovarian 
struma. 


Table I. The Iodine Content of Ovakian Struma Compared With That of Other 

Tumors and Organs 


MO. OF IODINE PER 100 OM. 

OP DRY SUBSTANCE 

Normal thyroid 

l.S 

Normal thyroid 

2.3 

Case 1. Thyroid-like jjortion 

0.673 

Case 1. Carcinoma-like portion 

0.004 

Case 2. Struma ovarii 

0.025 

Case 2. Cyst fluid from other ovary 

0 

Case 3, Struma ovarii 

0 

Cancer of breast 

0 

Cancer of ovary 

0.004 


PHARMACOLOGY 


Reid Hunt^® has discovered a pharmacologic test for thyroid. He found 
that the feeding of thyroid under certain precautions protects mice from 
acetonitril poisoning, while it makes rats more susceptible. The astonish- 
ing fact that the two closely related animals behave in an opposite way 
renders this test especially aecnrate. The test is carried out in tlie fol- 
lowing way, Yonng rats which have been kept on a constant diet are fed 
with the substance which is to be examined for its thyroid action. After 
a certain time an injection of acetonitril is given in different dosages and 
the lethal dose is determined. The lethal dose for untreated animals ’must 
be determined in a large number of rats or mice beforehand. 

It is unknown why thyroid feeding has this effect upon the splitting of 
the ae^onitril molecule. Acetonitril poisons by giving off liydroeyauie 
acid. The technical details of the animal experiments have been described 

liad all been used up for microscopic and chemical examination. The imsi- 
ive results obtained in the acetonitril tests thus represent minimum 
figiues. e should have expected still more strildng results if we had had 
he with the highest Wine content avaihWe Jot- tcetog Ifa 

erial fiom Case 2 fed to mice in different series of experiments with con 





358 


A-jMERICAN JOUBXAIi OP OBSTETRICS AND GYNECOLOGY 


tlie first specimen, which had a A'cry low iodine content, showed only a very 
slight thyroid effect in the aeetonitril tests. The iodine-free material from 
Case 3 had no effect. 

These experiments show that ovarian struma has the pharmacologic 
effect of thyroid in proportion to its iodine content. 



• « Untreated mice (controls) 

. Mice fed with iodine-containing Ovarian Struma 

.Mice fed with normal Ihgrold 

Fig. 10. — All oC the mice fed with the lodine-centaining ovarian struma survived a 
full dose (4/4). More than lialf of them survived 1% times the dose (6/4). Some sur- 
vived even the double doses (8/4). The curve for tlie mice fed with the ovarian struma 
and the curve for the mice fed witii the normal thyroid are to the right of ana above the 
curve for the control animals. 



= UntTccjled rats CcomItoIs) 

= Rats fed u/ith iodine-containing Ovarian Struma 

= Rats Fed with normal thitroid 

Pig. 11. — None of the rats fed with the ovarian struma survived a full dose (4/p. 
Even after 3/4 of the dose, only a minority survived. The curves for the rats fed with 
ovarian struma and the rats fed with the normal thyroid are to the left of and below 
the curve for the control animals. 


BIOLOGY 

Gndernatscli’^- in 1909 found that tadpoles rapidl}'^ develop into minia- 
ture frogs when they are fed thyroid. He and his coworkers in innumer- 
able, painstaking experiments have determined the tadpole effect of the 
different organs and of many chemical substances. Tims, thymus feeding, 
for instance, makes tadpoles large hut prevents, or at least retards, meta- 
morphosis, while other organs, like liver and muscle, are indifferent. But 



PIjA.XJT ; OVARIAN STUUTiIA 


359 


tliyroid feeding stands out as the only feeding which can hasten the meta- 
morphosis of the tadpoles considerably. Since there are biologic sana- 
tions in the development of larvae like tadpoles, many control eKperiments 
are necessary if one wants to have reliable results. _ In our tadpole expel i- 
ments also unfortunately we did not have the material from Case I with the 
liio-hest iodine content available, but the results with the material from the 
second case are striking enough, hlany of the tadpoles used for the experi- 
ments were photographed in order to have permanent records. Figure b 
shows four tadpoles fed with dried material from Case 2 together with four 
control animals from the same egg ball. The control animals^ received 
potassium iodide in their food corresponding to the amount of iodine wbicb 
the other animals received in the ovarian struma they weie eating. The 
animals fed with ovarian struma (upper row of Fig. 8) are smaller than 
the others ; they have distinct hind legs ; their tails are smaller. The shape 
of head and body in some of them is already frog-like. The material from 


the solid portions of Case 1, which contained very little iodine, and the ma- 
terial from Case 3, which contained no iodine, gave negative results in the 
tadpole tests. Control experiments with carcinoma of ovary were negative. 

These tests prove that biologically also, ovarian struma must be con- 
sidered true thyroid tissue. In conclusion therefore wm may assume that 
ovarian struma morphologically, chemically, pharmacologically, and bio- 
logically is true thyroid tissue. 


REFERENCES 


(1) PieJe, L.; Deutsche Med. 'Wchnschr. 28; 1002. (2) Mayer, A.: In ITalbnn 

Seitz: Biol. u. Path, dcs Weiges 5: ii, 861, 1926. (3) Moench, G. L.; Ztschr. f. 

Geburtsli. u. Gynak. 95: 459, 1929. (4) Wegetin, C.: Handbuch d. spez. patliol. 
Anatomic 8: 209,1926. (5) Masson, P.: Tumeurs — ^Diagnostics histologies 359; also 
see Wegelin 1. c. (6) Meyer, M,: Virchows Arch. 173: 538, 1903. (7) Non, M.; 

Monatsehr. f. Geburtsh. u. Gynslk. 34; 251, 1911. (8) Schauta, J.: Zentralbl. f. GjTiiik. 
No. 25, 1911. (,9)Kendall, E. C., and Bichardson, F. S.: J. Biol. Chem. 43: 161, 1920. 
iU)Evnt, Beid: Reprint No. 1026. Publ. Health Rep. Washington, 1461-1466, 1925. 
(ll)PZaMt, A.: Klin. Wchnschr. 10: 1803, 1931. (12) Gudernatsch, F.; In Handbuch 
d. Inneren Sekretion, herausgg. von Max Hirsch 2, Dief. 8. 

ABSTRACT OF DISCUSSION 


DR. ROBERT T. FRANK. — ^Dr. Plaut is to be congratulated on having found three 
struma ovarii out of the 70 which have been reported in the literature, and likewise for 
having given the final proof by his pharmacologic work to the statement that Pick 
made that these were true thyroid tumors. 


These tumors are also of interest from a clinical point of view. I have had the op- 
portunity of seeing two, the first one in which an ovarian tumor showed this honey- 
combed appearance with golden-yellow content forming practically the entire tumor 
with the exception of a small narrow piece of bone to which a tooth was attached. No 
other struma structures were found. The second patient was operated upon fifteen 
years ago. A large portion of tlie tumor appeared to be carcinomatous and yet the 
patient has remained well. In the literature, as far as 1 know, there has only been one 
case m which metastasis occurred. Therefore the carcinomatous portion of such a thy- 
roid struma need not be considered unduly disquieting to the clinician. 

Another point of interest is the fact that in many of these cases ascites is found and 
! P>-esent and when the pathologist reports “carcinomatous 

areas, the clinician is naturally much worried, but I feel that he should be reassured 



360 


iVJIKRICAN JOURNAL OF OIJSTETRICS AND GYNECOLOGY 


DE. G. L. MOENCH.— I Imve seen three of these cases. We tested for iodine in all 
of them, but could not obtain even a trace. One of them was a serous cyst and two of 
them uere dermoids; that is, to a small extent. The last one was particularly interest- 
ing because in this patient there were symptoms pointing to hj-porthyroidism, but we 
did not evaluate them properly, because with an ovarian cyst ordinarily you do not 
think of a thyroid tumor. She had tremor, irregular heart action, palpitation, and the 
blood iiressurc was higher before than afterwards. 

DE. S. H. GEIST. — Apropos of the case that Dr. Moench just mentioned, there is 
the well-known case in Erank^s book in which the patient was operated upon for what 
turned out to be a struma ovarii. She had the classical hyperthyroid sj'inptoms and 
follon-iug operation the patient wa.s well. I believe, in spite of the report of but 70 
cases of struma ovarii in the literature, that the condition must be more frequent. As 
Dr. Plaut has said, in the teratomas, and often in what we call dermoids, small areas 
of thjToid tissue, or thj-roid-like tissue, arc very common. There is not any question 
that a great many of these adenomatous areas may simulate thyroid structure, and 
without such convincing proof as Dr. Plaut has adduced one could not be sure that thej' 
are thyroid tissue. Nevertheless, morphologically they present all the evidences of 
thyroid. There is not any reason why there should not be thyroid in dermoids or 
teratomas, and there is not any reason why they should not undergo carcinomatous de- 
generation. We know in teratoma there arc commonly carcinomatous areas. In the 
follow-up in most of the cases of struma ovarii in the literature, it has been found that 
the patients remain well after what seems to be malignant degeneration. That does not 
follow in teratoma in which true malignanc}- in the intestinal or respiratory tract takes 
place with a groat tendency to recur. 

DE. PLAUT (closing). — I do not know if Kovacs’ case is identical with the one 
mentioned in the literature, where seven years after operation for ovarian struma ab- 
dominal carcinoma was found. Despite the man)' reports on the benign character of 
ovarian struma, I think it would bo well to watch these patients carefully for longer 
than the usual five year period. 

The reports of the tAvo patients in Avhich symptoms of hyperthyroidism disappeared 
after extirpation of OA'arian struma are very uiteresting. Unfortunatel)', there is one 
report about symptoms of hyperthyroidism appearing after removal of an ovarian 
struma. Thus, Ave must be careful in our interpretation of clinical signs no matter how 
suggestiA’e they may be. 

Dr. Moench referred to a case in Avhich there was a serous cyst in the ovary, which 
leads to refer to another point of morphology. The ovarian struma has nothing to do 
Avitli the cystadenoma, either the pseudomucinous or the serous type. lYe have talked 
about mucin in the ormrian struma, not about pseudomucin. The dermoid cyst of the 
OA’ary and the cystadenoma also liaA'c no direct relation to each other. They are often 
found combined, simply because they are both frequent diseases. Thus, in Dr. Moench s 
specimen there must have been an ovarian struma and a cystadenoma independent of 
each other. 

1 do not AA'ant to leave the impression Avith you that many specimens of ovarian 
struma contain carcinomatous elements; on the contrary, only a minority of them do, 
and most specimens histologically are benign. In the older literature you aaHI find 
statements that ovarian struma is malignant. It is not. 

In a large number of reports about ovarian struma, the bean shape or kidney shape 
of the tumor is mentioned. This cannot be accidental it has been observed too often. 
This peculiar shape may be helpful in clinical diagnosis, notably Avhen it is combmed 
with ascites in a patient aa'Iio does not give the impression of being a cancer patient. 
Therefore it might be possible occasionally to make a clinical diagnosis of oraiian 
struma. It Avould be very interesting to do a metabolic test on such a patient before 
operation and to repeat the test after the effects of the operation have subsided. 



THE USE OF FOLLICULIN IN INVOLUTIONAL STATES 

Eliier L. Sevringha-os, M.D., i\LvDisoK, Wis. 

(Frovi the Department of Meclicinc and the Wisconsin General Hospital, UniversiUj 

of V'isconsin) 


A S A RESULT of tlie production in commercial amounts of follieulin, 
the hormone from the graafian follicle, considerable numbers of 
women have been relieved of the discomforts and disabilities incident to 
the menopause. In previous reports the results obtained in the common 
vasomotor disturbances have been cited.’- - The similarity of some meno- 
pausal syndromes to thyrotoxicosis has been described and the .symp- 
tomatic relief with follieulin has been demonstrated.'"^ It is the object 
of the present eommunieation to report the success attained "when similai 
treatment was given to a series of women who demonstrated chiefly the 
psj^chie and nervous phenomena that arc commonly associated with the 


involutional state. 

Manifestations of the climacteric are protean in type. The nervous 
S3^stem, central and peripheral, the vascular, glandular, digestive, and 
reproductive s3"stems are frequently disturbed during this period. Con- 
sequently it might be thought that an attempt to relate all these dis- 
turbances to a single fundamental change in function would be futile. 
The problem is no more impossible than the now accepted unitaiy ex- 
planation of the man3' pathologic processes seen in the study of a series 
of diabetics. In neither case has a complete chemical or i)h3'siologie 
mechanism been even suggested to explain the problems. But in the case 
of both diabetes and the menopause it has been the preparation of fairl3’- 
pure hormone materials of standardized potency which has made the 
unification of thinking possible. In using therapeutic results as evidence 
for the nature of disease caution is necessary. Hormones can be shown 
to have effects which are useful therapeutically even though there is no 
evidence that a deficiency of the hormone existed before treatment be- 
gan. Nevertheless the results from the use of follieulin have been so 
gratif5^ing in scope as well as in frequency of response that they-’ suggest 
to the author a replacement therapy for graafian follicle deficiency. 

No listing of all possible symptoms of the menopause will be made. It 
m of interest to note the frequency of a few of the commoner features. 
For this purpose a series of 32 case records is available. These have 
not been included in the previous studies mentioned. They were all ex- 
amined by the author, and the inquiry as to symptoms as well as judo-- 
ment about such matters is therefore fairly uniform. None of the pa- 
tients included was psychotic to the extent that she had been considered 
foi commitment to .any psychiatric institution. A number were studied 

361 



362 


A.MERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


as menopause eases in spite of the existence of some other complaint that 
led to hospitalization. 

Half the group, 16, noted paresthesias such as tingling, pruritis, for- 
mication, or numbness of extremities. Insomnia -was reported b 3 ’’ 19 as a 
distressing factor, which had not been present previousl}'^, and for which 
there was no other evident cause. It seems espeeiallj’’ characteristic of 
this insomnia that the woman will sleep well for the first few hours, and 
Avaken between 2 and 4 a.m., to fall asleep again onlj’’ after a long pe- 
riod of sleeplessness. This feature is variable, of course, but the morn- 
ing Avakefulness is far more striking than the inabilitj' to fall asleep when 
first going to bed. 

There Avere 17 cases in the group of 32 who gaA'^e definite histories of 
psychotic features Avhich had developed during the period of disturbed 
menstrual rhythm. The complaints ranged from increased “nervous- 
ness” to the tj^pical involutional picture including despondencj’", sub- 
jective inadequacy for the usual tasks and responsibilities, emotional 
labilitj’-, suspicious attitudes, and frequent contemplation of suicide. 
Of this group onlj’- two had consulted a psychiatrist. None had pro- 
gressed to an intensit}'’ of symptoms which required institutional man- 
agement. Usually the process had continued for a matter of weeks to 
months Avhen the patients were first seen. 

A case summary Avill serve to illustrate the problem as it is presented 
to the familj'’ physician. 

Mrs. S. noted beginning irregularity of menses at the age of forty-three. Her 
family uvere very much concerned about her mental condition because of failing 
memory, continuous Avorrj-ing, and despondency wth suggestions of self-destruction. 
She was working as a telephone operator, and her changing mental attitude made it 
seem that she would have to stop the work which helped support the family. In- 
quiry showed that she noted vertigo, weakness, hot flashes, paresthesias, and was 
much troubled with insomnia which had not previously been a problem. This woman 
was given small doses of folliculin by injection, and noted improvement at once. 
After two months it was found possible to discontinue the treatment entirely. Menses 
became regular again and no treatment was required for 12 months. A second attack 
was recognized promptly. Treatment was limited to theelol, 0.2 mg. or 100 units, 
twee daily, by mouth. Belief was complete within a few days and after four weeks 
the drug was omitted Avithout return of the symptoms. There is reason to believe that 
she Avill again require assistance Avhen the menopause once more begins to show symp- 
toms. 

In the therapeutic program the tAA’^o items regularly used have been 
psychotherapy and the use of folliculin. The ps^'^chic approach hardly 
merits a name, for it has consisted simply of explaining to the patient • 
the nature of her difficulty. The dependency of the mental picture on 
the phj'^sieal change AAffiieh she can recognize has been described brieflj’', 
and then the woman has been assured that this mental disturbance is 
temporary. Assurance is gNen that no permanent psychosis is to he ex- 
pected. The similarity to marked fatigue has been suggested. The com- 
plaints of inadequaej^ for the usual tasks and responsibilities have been 



SEVRINGHAUS; EOliUCTUN 


363 


ignored. Occasionally the patient has been told that the inability is 
iSirely subjective and temporary. It has not seemed necessary to as- 
semble objective evidence or testimony of others that the ivoman is still 
doing her work well. This sense of inadequacy has become a minor mat- 
ter when a rational attitude to the whole climacteric was secured. I he 
morbid thinlcing about suicide is frequently not volunteered by the pa- 
tient, of course, but when tendencies to despondency arc mentioned a 
direct question about the matter of self-destruction has frequently 
elicited prompt admission of these thoughts. As a consequence of casual 
mention of this tendency in the resulting discussion, it is evident that 
great relief has been given the patient wdien she realizes that the suicidal 
problem is a part of this climacteric change. There has been no reason 
to suppose that casual approach to this feature has caused any resent- 
ment or started anj’’ morbid thinking when such thoughts had not been 
previously recognized by the patient. To experienced psychiatrists this 
matter of rationalizing the involutional state with the patient is nothing 
new. But it is distressing to realize that the general practitioners of 
medicine, young and old, are not aware of the desirability of such friendly 
approach to a problem that occurs chiefly in general practice. Even 
when hormone therapy is not used this psychic approach is available, 
and its value, not easilj'’ measured, is obvious when once tried. 

It must be admitted that the success of the conversational method has 
been supported by the assurance of physical relief Avith the administra- 
tion of follieulin. Erom the results here reported it would be difficult 
to decide just which sj^ptoms are amenable to one and which to the 
other part of the therapeutic program. But in those cases where the use 
of the medication has been interrupted patients have quickly convinced 
themselves that the hot flashes, insomnia, paresthesias, and despondenc}^ 
are relieved by the follieulin, not by the doctor’s words. Of the 17 pa- 
tients with psychotic manifestations, the use of the follicular material 
has been carried out with 15 for a long enough time to see results. The 
results were distinctly questionable in two, but the other 13 showed un- 
doubted improvement within a few days. Several of these have been 
followed for periods of 8 to 21 months to insure that results were being 
maintained so long as the treatment was continued regularly. Hot 
flashes and paresthesias are usually the first symptoms to disappear. In- 
somnia has been reduced almost as quickly. The patients have become 
cheerful again, been able even within a matter of a week or two to con- 
sider the former attitude with a smile, and in two cases have been able to 
resume occupation which members of the family were considering im- 
possible due to the mental instability. 

The most ^satisfactory cases to manage Iiaye been those women in 
whom It ts evident that a long standing vasomotor and emotional in. 
stability lias csisted, since long before the menopanse. Failnro to seonre 
complete relief from the varions diseomforts whieh such 



364 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


plain of is not surprising. Sometimes these patients have denied that 
any marked relief vas obtained, hut thej"^ have nevertheless eontinued to 
purchase the eommereial follieulin prcjiai’ation recommended even 
though expense was an important item. Continued use of hj^Dodermic 
or A^aginal suppository medication in spite of these disagreeable features 
may also be taken as evidence of .subjective relief. 

The age range of this group of cases is from thirty-two to fifty-six 
years. There are 10 cases aged forty-one or less, of whom special men- 
tion is required. Artificial menopause had occurred in 6 of this sub- 
group. One other was thought originally to be th.yrotoxic, and her case 
resembles those reported previously.^ The remaining 3 should ap- 
parently be considered as examples of hypofunction of the ovaries, 
rather than as menopause cases. A'o clinical criterion can be suggested 
for this dilferentiation, but the ages, (thirty-two, thirt.Y-thrce, and forty) 
made the true elimacleric questionable. Menstruation was irregular, 
regular, and absent, respectively, in these three patients. The sjnnp- 
tomatie picture was so typically involutional that a therapeutic trial of 
follieulin was made and was followed by success of a surprising degree. 
In two patients regular menstruation has been reestablished. One of 
them prefers to believe that her clifhevlties can not be associated with the 
menopause but must be psychogenic in origin. But she returns to the 
use of follieulin repeatedl.y when she attempts to do without it. 

The manufactiu’crs of the different preparations of follieulin have ad- 
vised the use of daily doses as high as 200 units. A not uncommon attitude 
ha.s been to suppose that if a little heliJS, more would be still better. The 
author’s experience leads to recommending an upper limit of about 40 
units per da 3 ’' in the treatment of the menopause. The reasons are not 
so mnch the cost of the material, but the unfavorable action of larger 
doses. Overdosage has caused the reappearance of menses in one truty 
menopausal woman, has provoked menorrhagia and increased d,ysmenor- 
rhea in an eai’ly menopausal patient, and a single dose of 50 units pro- 
duced in still another woman a violent and persistent hot flash with great 
discomfort, although this was folloAved bj’’ freedom from such symptoms 
for two daj^s. Conversation with clinicians who liaA’^e failed to secure 
benefit from the follieulin treatment in cases Avith inA'olutional ps5>’chosis 
has rcA’^ealed the fact that A^eiy lai’ge doses Avere being emploj'^ed. It is 
possible that the failure AAms due to the excesstye dosage. Small doses 
seem AA’^orth considering also for the treatment of ^munger patients, since 
it appears that excessively large doses are apt to lead to ovarian atrophy. 
This may be brought about bj’’ the inhibitoiy action of the large doses of 
follieulin on the anterior pituitaiy function, Avith a secondary lack of 
pituitary stimulation to the oAmries. In AdcAV of these experiences and 
since there is no knoAAoi method of estimating the required dosage in ad- 
vance, the therapy in these cases has been carried out by the use of 10 
to 25 units at one time, giA’^en once or tAvice daily. Theoreticallj' the more 



SEVKIXGHAUS : FOLEICUEIN 


365 


frequent small closes are undoubtedly better than larger and less fic- 
qu.ent ones.'* 

The patients u’ith artificial menopause have been the most diflicult to 
free from symptoms by follicrrlin therapy. The difficulty has been met 
in part by the use of somewhat larger doses. Evidence for this more re- 
fractory nature of the symptoms in patients with an artificial menopause 
is the longer interval required after the beginning of treatment before 
there is evidence of improAmment. Usually this interval does not exceed 
two days, but it has been as long as trvo Aveehs in the radiated or operated 
cases. Early failure or lack of result from small doses need not lead to 
abandonment of the treatment, but should call for persistent use of 
moderate doses. 


The refractor}' nature of the artificial menopause is illustrated by the case of 
Mrs. H., aged thirty-six. Menstruation began at age fifteen, and was regular every 
twenty-eight days, duration five days. There arc two children. For reasons un- 
known to us appendectomy done at age twenty-six was accompanied i)y removal of 
both ovaries and tubes. There has been no menstruation since, but the patient has 
complained of hot flashes, frequent attacks of irritability and weeping, weakness and 
vertigo, headaches, amblyopia, and scotomata. At age thirty-four an operation for 
adhesions was performed. Since then there have been xjalpitation, burning and 
gnawing epigastric pains not relieved by food, variable appetite with frequent nausea 
and vomiting. She complained of constipation but had mucous stools. She has re- 
cently been continually discouraged and despondent. Pliysical examination showed 
nothing unusual except a soft systolic murmur at the ape.x, disappearing on arising, 
blood pressure 122 systolic, 83 diastolic, general colonic tenderness, and a palpable 
thyroid isthmus. Laboratory data were of no significance. Kclicf from the diges- 
tive symptoms was partial follorving the use of bland diets and belladonna, Fol- 
liculin was administered in 10 unit doses (amniotin) twice daily for ten days. Be- 
lief from the numerous comi)laints was definite but far from complete. Change to 
use of 25 units once daily (theclin) gave slightly more relief. The patient insisted 
on discharge because of the cost of treatment. Report by mail subsequently showed 
that there had been practically a complete relapse at homo, since she was unable to 
pay for the expensive medication. During the hospitalization omission of the medi- 


cation for one day had allowed a return of frequent hot flashes and of depression. 
The refractoriness of this case is appreciated only by comparison with the prompt re- 
lief obtained in the case described above and in those previously reported.'- ' 

Mrs. E., aged forty, had been diagnosed ns suffering from cervical carcinoma 


(biopsy) and had radium implantations in June and August of 1928, followed by 
deep radiation in October and January. In January, 1929, acute symptoms led to 
appendectomy and hysterectomy in another hospital. She was treated for pyelitis 
and cystitis from July to November, 1929. In September of this year she first re- 
ported hot flashes, palpitation, gas pains and nausea. Postoperative hernia repair 
and hemorrhoidectomy were done in February, 1931. April 30, 1931, she reported 
for treatment because of insomnia, hot flashes, pai-esthesias, depression and con- 
templation of suicide. Pelvic examination revealed vaginal and cervical atrophy and 
rectal spasm. Rectal dilatation was done. At this time follieulin was begun in doses 
of 10 units daily (amniotin). After 5 weeks she reported that she was still having 
one or more hot flashes each day, but sleep was improved, and the depression w-S 
greatly relieved She began to note that her feet always «fclt heal-y’^ince 
die theiapy The treatment was changed to 20 units daily (theelin), and the report 
in one month was that she continued to improve but still noted about one flashier 
night. Return to the use of 10 units of amniotin for the third month was followed 



366 


A.JIERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


by still more marked improvement. She felt her best during the first hours after 
the morning injection. Eelief was so complete that she desisted from the treatments 
after two more weeks. This was in spite of the furnishing of the medication by a 
charitable group. The visiting nurses who had observed the patient for many months 
were amazed at the change in personality. Tlie patient returned to work in a beauty 
parlor and was able to assume most of the support of her four sons. 

Pour months later she returned because of recurrent vertigo, “nervousness,” hot 
flashes, and insomnia. The urinar}’ tract was also showing signs of inflammatory re- 
action. She was started on the use of folliculin orally, using progj-non tablets. Ee- 
lief of symptoms has again been definite while taking 30 unit tablets twice daily. 
(This dose is approximately equivalent to G units hypodermically, judging from the 
use of the material in castrate rats in this laboratory.) This patient has evidently 
had an artificial menopause induced by radiation, with symptoms appearing slowly 
as often occurs. Tlie vasomotor and psychic disturbances were no more intense than 
in a number of the spontaneous menopausal cases included in this series, but the 
duration of the treatment necessary to obtain relief from symptoms is strikingly 
greater than that usually observed. Not all the artificial cases have been so refrac- 
tory, but the only refractoriness has been in the artificiallj' induced menopause cases, 
so far as the author’s experience goes. 

This observation about the relatively refractory nature of the artificial 
menopause leads to speculation about the mechanism involved. It is evi- 
dent from animal -work that the anterior pituitary exerts a stimulating 
activity upon ovarian development and activity. Likewise the ovary ap- 
pears to exert a depressing effect on the anterior pituitary, thereby ob- 
taining a djmamic equilibrium. The preliminary results from Flub- 
mann’s clinical materiaP suggest that the menopause may be accom- 
panied by excessive activity of the anterior pituitary. It may be in 
keeping to suggest here that the vasomotor manifestations of the meno- 
pause, at least, might be due to pituitary overactivity. This may be of 
the anterior lobe, or perhaps associated disturbance of the posterior 
portion might also be excited. Certainly disturbed or decreasing activity 
of the ovaries cannot be directly charged with the disturbances, since the 
symptoms of the menopause occur in most marked fonn and for periods 
of years after complete castration. The longer duration and the greater 
difficulty in management of the artificial menopause cases might be ex- 
plained by assuming natural tendency of the anterior pituitary to reach 
a senescent stage of reduced activity in the fifth or sixth decades. If the 
pituitary and ovarian activity decline together, an uncomplicated 
climacteric would be anticipated. If the pituitary declined pTematurelj’, 
the picture would be that of the premature but quiet menopause. But if 
the pituitary outlasts the ovaries the picture will include the various 
clinical manifestations usually associated with the disturbed menopause, 
i. e., vasomotor, neurological and psychic instability. These speculations 
wiU become susceptible of test as the methods of assay for ovarian and 
pituitary hormones in normal blood are elaborated. Progress in this 
technic is slow, in this laboratory as in others. At present it can at least 
be said that the above hypothesis is not inconsistent w’ith kno'wn facts 
from the animal work which has been reported in the past decades. 



SEVRINGHAtrS : rOLElCUIAN 


367 


Direct eivdence tliat tlie pituitary factor per se is a canse of at least 
the vasomotor symptoms may he near at hand. Several patients have 
recently been treated in this hospital with follntein, hccanse of amenor- 
rhea or of sexual infantilism. Some of them have reported the disturb- 
ances resembling hot flashes, occurring within the first hour or two after 
the hypodermic injections. Follutein is a preparation from the urine of 
pregnant women, made in the laboratories of E. R. Squibb and Sons. It is 
laiown bj’’ animal tests in the laboratoi'y of the manufacturer and in this 
laboratory likewise that follutein contains factors resembling or identical 
with the anterior pituitary materials which stimulate follicular growth 
and also luteinization. Details of these studies udll be published shortly. 

Incidentally it may be mentioned that in the present series of 32 cases 
only 13 are obese. A few of these have evidently been obese since before 
the climacteric was approached. The common clinical tendency to as- 
sociate obesity with the age of the menopause is by no means always 
justified. There may of course be more than an incidental connection. 
The work of Smith® demonstrates the obesity which follows disturbance 
in the hypothalamic region in rats. It is not improbable that the result 
of castration or of the spontaneous menopause may be an uninhibited 
activity of the anterior pituitary udth consequent disturbance in the 
neighborhood just sufficient to affect this “obesity center” in some cases. 
Again there are only 10 of these 32 cases with hypertension, illustrating 
the inconstant tendency to this manifestation of the menopause. Al- 
though the association of h5q)ertension with the pituitary gland is less 
certain than that of the gland and obesity, the variable picture sketched 
above may be of significance here also by posterior pituitary disturb- 
ances. It is not to be forgotten that the involvement of the adrenal 
cortex in the gonad hormone system may probably have to be reckoned 
with in the blood pressure problem. 

The preparations of folliculin employed have included amniotin and 
theelin. The former has been used with equal success in hypodermic in- 
jections or in the vaginal suppositories. The choice has been made on 
the basis of convenience to the patient. Grateful acloiowledgement is 
made to the laboratories of the E. R. Squibb and Sons Company and to 
Parke, Davis and Company for the supply of much of the amniotin and 
theelin respectively which has made possible this study. Exactly similar 
results have been obtained more recently using theelol. 




_ In a series of 32 menopausal cases hot flashes occurred in aU, paresthe- 
sias m_16, insomnia in 19, and psychotic pictures in 17. Obe^sity was 



368 


AJIERICxVX JOURNAL OF OBSTETRICS AND GYNECOLOGY 


The use of simple ps.yehotlierapeutic procedures and small doses of 
follieulin daily or oftener has been found very helpful in the psychotic 
cases as well as in the simpler vasomotor t 3 ^pes and the pseudothju'otoxic 
types previously reported. Disadvantages of large doses of the hormone 
are pointed out. The refractory nature of the artificial menojiause leads 
to a discussion of the possible relationships of the pituitary and the 
ovaries at the age of the climacteric. 


REFERENCES 

(1) Scvringhmis, E. L., and Evans, J. S.; Am. J. M. Sc. 178: 638, 1929. (2) 

EamUen, E. C.: Endocrinology 15: 184, 1931. (3) Sevringlians, E. L.: Endo- 
crinology 15; 536, 1931. (4) Dodds, E. C.: Am. J. OnsT. & Gtnec. 22: 520, 1931. 
(5) Flnlmann, C. F.: Endocrinology 15: 177, 1931. (6) Smith, P. E.: Am. J. Anat. 
45: 205, 1930. 


RADIATION THERAPY IN GYNECOLOGIC MALIGNANCY* 

Ira I. ICcPLAN, B.Sc., M.D., New York City 
Director Division of Cancer, Department of Jlospitats. Visiting Eadiation Therapist, 

DcUevuc Hospital 

(From the Gynecological Service, and the Eadiation Therapy Service, Bellevue 

Hospital J 

T O CARRY out properlj’’ the procedure which is necessaxy to ir- 
radiate g 3 ’'necologic conditions efficientl 3 ^ the radiation therapist 
must be a elinieiau and have available a standai’dized x-ray apparatus 
and a sufficient amount of I'adium energ 3 ^. The therapist must be 
thoroughly familiar with the pli 3 '^sical and biologic factors of radiation 
therap 3 ’', for it is often essential to choose what form of irradiation will 
be suited to any one case. In a general way we have found it more 
advisable to use the x-ra 3 ^ (1) for palliative treatment; (2) for curative 
ti'eatment where lai’ge areas must be iiTadiated; (3) in cases where in- 
accessible lesions are present; and (4) in conjunction with radium 
therap 3 ^ and surgery. Radium, on the other hand has proved most use- 
ful (1) for local or surface application; (2) for intraorificial or jntra- 
tumoral treatments; and (3) as a distance pack where large quantities 
of radium are available. 

On account of the economic status and the type patient referred to a 
free municipal hospital it has not been feasible to obtain completely 
satisfactory follow-up records. In man 3 ’- instances the patients never re- 
turn to this clinic and no ti’ace can be found of them at their given 
address. 

The present discussion is eoneeraed with the malignant g 3 Tiecologic 
conditions we treated in 280 pidmary malignant cases during 1924-1931. 

‘Read before the Section of Gynecology and Obstetrics, New lork Academy of 
Medicine, March 22, 1932. 



KAPLAN; RADIATION THERAPY 


369 


ALIGN AN CY OF THE VULVA 

111 our series this conditiou is not common and occurred mostly among 
■women above 50 years of age. During the past 8 years ive have liad re- 
ferred to our service only 12 cases, the youngest was 30 and the oldest 
74 years of age. Five women ivere between 51 and 60 years and 3 be- 
tween 61 and 74 years of age. Onlj’^ 5 of the women liad ehildien 
although 11 were married. Four were widows. Only one single woman 
of 56 years of age was referred for this condition. Two women ivere 
of the negro race. In 1931, 4 patients ivcre alive and ivell, 5 were dead, 
and the result in 3 cases ivas not known. 

Treatment in all cases consisted of a combination of radiation and 
surgery. Preliminary irradiation of the inguinal lymphatics with high 
voltage x-rays was folloived by surgical removal and where possible with 
the high frequency current. In extensive cases, intratumoral treatment 
with radium ivas carried out, and the remaining growth ivas removed 
by high frequency current when the lesion did not respond to irradiation. 


CARCINOJIA OP THE VAGINA 

Primary carcinoma of the vagina is a rare condition. "We have had 
4 eases, all in ivhite ivomen. Treatment consisted of x-ray irradiation 
of the vaginal lymphatics and local radium therapy to the vaginal 
lesion. Of the four women treated 3 were married, and one was single. 
The youngest was a married "woman of 28 years, and the oldest ivas a 
single "woman of 35 years. The others ivere 36 and 45 years of age. 
Only one had children. Three cases "were seen alive in 1929 and one was 
reported dead. 

CARCINOMA OF THE URETHRA 

Urethral carcinoma is occasionally a primary lesion. In our series we 
have had t"wo eases ; both were treated by x-ray therapy to the inguinal 
lymphatics and suprapubic pelidc areas, followed by radium therapy to 
the local lesion. In one case intratumoral radium "was used ; in the other 
a local application was applied to the surface of the lesion. Both eases 
were widows aged 60 and 67 respectively, and both white women. 
Both cases are alive but in poor condition three years after treatment. 


CARCINOMA OP THE CERVIX 

Carcinoma of the cervix has been best treated by irradiation. For the 
past 8 years on the gynecologic service at Bellevue, this method has 
superseded all surgical methods for this condition. Treatment con- 
sists of a combination of x-rays and radium therapy. The x-rays are 
used to control uterine bleeding, suppressing menstruation altogether 
_o irradiate possible adnexal involvement, and the associated lymphatic 

-- ays. The radium technic is a modified form of that in use at the 



370 


^MERICA^' JOURNAL OF OBSTETRICS AND GYNECOLOGY 


Curie Institute in Paris, as previous!}’- described by the -writer in 1927y 
For the past two years we have changed our method somewhat. Fol- 
lowing tlie usual course of pelvic x-ray therapy, another course is given 
one month after the radium has been applied to the cervix. The second 
treatment of the pelvis by x-rays has been found necessary to take care 
of recurrences and pain which oeem-red in many cases -which had ap- 
parentl}^ completely healed as a result of radium treatment. 

From our experience during the past S years we have found this 
method very worth while. A statistical report of our eases treated has 
been given elsewhere.- Since publishing this report we have treated 
29 additional cases during 1931 or a total of 167 cases and our results 
have continuously improved. In cases where the local cervix lesion is 
extensive and cauliflower in appearance, high frequency removal of the 
tumor growth is done to facilitate the application of the radium. In 
all cases treatment by radium is applied to both the uterus and the 
cervix. 

CARCINOJIA OP THE UTERUS 


Uterine carcinoma -we believe may Avell be treated by irradiation as 
Avell as by surgery, Treatment is carried out by x-ray therapy to the 
pehns, acting on the adnexa and uterine body, and by radium inserted 
into the uterine canal, and, to the parametrium by a vaginal applicator. 
The radium dosage for the uterus itself must be larger than that em- 
ployed for the parametrium, it is applied over a long period of time, 
namely, 5 to 8 days. In advanced cases, or those in which operation is 
contraindicated, palliative pehde x-ray thei-apy alone is emplo 5 ''ed. 'We 
have felt that irradiation is preferable to surgery in these cases but if 
operative treatment is employed, we advise both pre- and postoperative 
irradiation. 

During the period of 1924 to 1931 there Avere 54 cases referred to 
the Radiation Therapy SerAUce for treatment. Fifty-three Avere white 
Avomen, and 1 Avas a negress. A microscopic diagnosis was made in all 
cases, all of Aidiich U’ere of the adenocarcinoma tj’pe. Of these, 20 had 
had a previous hysterectomy. One ease had a colostomy for obstruction 
and no hysterectomy. Thirty-three AA’ere treated by irradiation alone; 
these Avere patients in whom operation A\’as contraindicated on account 
of serious associated disease or too far advanced local lesion. Of the 
54 eases, 47 Avere gentiles and 7 were JeAvish, 50 were married or 
AA'idoAved, 3 Avere single women, in 1 the marital state was not recorded. 

The youngest Avas 30 years of age and the oldest 84. Most cases weie 
in the 41 to 50 year period. The age grouping was as follOAvs : 


30-40 41-50 51-60 61 ana over 

8 23 25 8 

Of the married women 34 had one or more children, and 14 had none, 
3 Avere not recorded. TAvelve are ItnoAvn to be dead, 21 knoAATi to be alive, 



KAPLA-N^- radiation therapy 


371 


and 21 oondition vmlmomi. 0£ the 21 living patients 11 had l.ad 
hysterecfoiuy and irradiation and 10 had irradiation alone. 

1924— 2 cases— 1 knovfn dead 2 years after treatment. 

1 rmknovm. 

1925 — 1 case — 1 ^nlkll0^vn result. 

1920 — 4 eases — 1 known dead 5 years after treatment. 

1 living and fair condition G years after treatment. 

2 unknown results. 

1927 — 0 cases — 1 known dead, living 1st year. 

2 unknown results after 2 years. 

3 eases living and in good kcaltli 5 years after treatment. 

1928 — 6 cases — 1 knorvn dead IS months after treatment. 

2 unknown results, 1 of these alive 3 years after treatment. 

3 living and well 4 years after treatment. 

1929 — 8 cases — Q known dead, 1 and 2 years after treatment. 

3 unknown results 1 and 2 years after treatment. 

3 li\*ing. 2 cases 2 years after treatment, eondition poor. 

1930 — 16 cases — i known dead 1 ye.ar or less after treatment. 

1 known died klarch, 1932 — 2 years after treatment. 

3 unknown results. 

8 living. 

2 cases 1 year after treatment. 

0 cases 2 years after treatment, health good. 

1931 — 11 cases — 1 known dead. 

3 unknoum results after 1st year. 

7 living at present over 1 year after treatment. 

CARCINOMA OF THE OVARY 

Carcinoma of the ovary tvhen operable is treated preoperatively and 
postoperatively by x-rays. In our opinion the best results are achieved 
ivhen the bulk of the tumor growth and adjacent tissues are removed 
following preoperative irradiation. In cases where ascites is present, 
the ascitic fluid is withdrawn before irradiation. In advanced cases 
palliative x-ray therapy to the pelvis is indicated, and in some instances 
we have seen a previously inoperable case become operable to such an 
extent as to allow for removal of the bulk of the tumor growth. Further 
iri'adiation w'ith x-ray therapy has ameliorated the condition sufficiently 
to permit a comfortable existence. During the period 1924 to 1931, there 
were 30 cases treated, 26 by operation and irradiation and 4 by irradia- 
tion alone. The youngest was 11 and the oldest was 65 years of age. 
There was one ease of a girl of 15 years of age. The grouping of cases 
according to age was as follows : 


10 


11 


There were 19 married, 9 single and 2 cases in which the marital state 
was not stated. Of the 19 married women, 12 had children and 8 had 
no children. There were 3 patients of the Jewish faith. Twenty-eio-ht 
were white and 2 were colored patients. The results are as follows 



372 


AMKRICAX JOUKXAL OK OBSTKTmcS AND GYNECOLOGY 


Nine are known to bo dead, and 7 living and well at present, aU having 
been treated hy irradiation and siirgeiy. In 14 the follow-up is lacking. 

19-3 1 case — last seen 1027 good condition. 

19_6’ 5 cases 2 dead 1 year sifter treatment. 

2 unknown after 1 year. 

1 alive and well February, 1932, 6 years after treatment. 

1928 — 4 cases — 1 dead during 1st j-ear. 

2 unknown after 1st year. 

1 alive and well 4 years after treatment. 

1929— 4 cases— 1 known dead, 2 years after treatment. 

3 results unknown after 1st year. 

1930 — 10 cases — 2 known dead during Ist year, 

G unknomi after 1st year. 

2 alive and well, 2 years after treatment. 

1931 — G cases — 3 known dead in 1st year. 

3 alive and well 1 j'ear after treatment. 

CAUCINOJtA OK THE FALLOPIAN TUBES 

During the past 8 years we have liad occasion to treat two cases of 
primary cai'cinoina of llic fallopian tubes found ipion operation but 
not preopei’afively diagnosed as such. Botli cases were white women, 
ages 29 and 32 respectively; one had had cliildren. One patient is still 
alive after two years, the other quickly metastasized to the viscera, 
terminating fatally v'ithin a short time. Surgery followed b}"- x-ray 
therapy was used in both cases. 

CHORIONEPITHELIOJIA 

Last year there was referred for irradiation a case of chorion- 
epithelioma ; this was postoperatively treated by x-ray therap 3 L In our 
opinion the most efficient procedure for this tj^pe of ease is surgery 
plus irradiation. As this is an embiyonic type tumor, iiTadiation should 
control its further grOAvth and prevent recurrence. This patient was 
a married ivliite woman, age 44, who had had S children premousljL 
She is still alive one j’-car after treatment. 

There was one case of teratoma and one case of lij'^datidifoi'm mole. 
The ease of teratoma was in a single girl of 28. She was treated bj* 
operation and radiation but died shortlj’" after treatment. The hydatidi- 
form mole occurred in a white maw'ied woman age 35 who had had foui 
children. She was treated bj’' operation and irradiation and is alive and 
well two ymars after treatment. 

From time to time there have been referred to us for treatment cases 
of recurrent carcinoma following h 5 ’'sterectom 3 ’’ done elsewhere. The 
irradiation procedure depends on the condition of the patient and the 
extent of the recurrent lesion. In manj’' instances the condition is so 
advanced that only custodial care is indicated. In several eases, hoAV 
ever, treatments bj^ x-rays to the pelvis and radium to the vaginal sui 



KAPLAN: RADIATION THERAPY 


373 


face of tlie lesion lias completely healed the condition and prolonged 
life in comfoi't. Report of the above eases is not included in this papei. 

CARCINOMA OP THE BLADDER 

Carcinoma of the female bladder has been treated bj'' x-rays tlirough 
the pelvis and occasionally by intratnmorally radium therapy in the 
bladder. In operable cases x-ray therapy suprapubieally has sup- 
pressed hemorrhage and ameliorated the severity of the pains and has 
made the later end of the patient’s life more comfortable. There were 
6 eases in our series in patients over 45 years of age. The most severe 
symptoms of hematuria were relieved in all eases. There were 3 single 
and 3 married women. 

In our work we have found the direct association with the gjmeeologic 
staff very helpful. Their cooperation has proved of value in the several 
cases of postradiation sepsis. In eases where adnexitis occurs or wliere 
the culdesac becomes filled with pus, surgical interference is necessary 
to relieve the eonditioir and often saves life. 

CONCLUSIONS 

Radiation therapy is an essential aid in the care and treatment of 
malignant gynecologic conditions. 

It is the method of choice in the treatment of cancer of the cervix. 
When properly applied, irradiation ameliorates the severity of the 
disease even in so-called hopeless eases. 

Irradiation must be applied only by one trained in the proper ‘use 
of x-rays and radium, and adequate equipment must be available. 
Report is made on 280 cases treated during the period of 1924 to 1931. 
Cooperation with the gynecologist is essential in order to achieve the 
best results. 

REFERENCES 

ijl) Am. J. Roentgenol. October, 1927. (2) Am. J. Roentgenol. November, 

55 East 86th Stkeet. 



INFORMATION REGARDING GONORRHEA IN THE 
IMMiVTURE FEMALE 


Goodrich C. Sciiauffler, M.D., and Ci.ifford Kuhn, M.D., 

Portland, Ore. 

(From the Department of Gynecology, University of Oregon Medical School and The 
Portland, Oregon, Free Dispensary) 

I T IS common knowledge that the gonococcus requires for its growth and 
the development of its pathogenic characteristics, a “harbor of infec- 
tion.’’ In exposed locations, or where it is subject to even mild noxious 
agents, or in competition with almost anj’’ other bacteria, the gonococcus 




Fi!?. l-B. 


between hymen and 

Fig. 1-A. — tsarinoiin aiea in fust^beneath cutaneous surface; 

labium minus ; h. lU’men ; d.o. nficates area shown in high powei 

gl. rudimentary gland tubules. The small square jnuiv-ii 

(Fiff l-B). - ' — ^ are 


i,i<'ig. l-B). In Fie- 1-A gl-t. gland tubules. These are 

Fig. l-B. High power area ‘"..A'flrictures found in a thorough examma- 

simple early gland tubules, tlie only infant Even these rudimentary 

of the tissues of a stillborn and of were apparently cut just short of their 

glandular structures are notably scarce. These ueie appai 

entrance Into the duct. 

becomes impotent and perishes. Only in the deep 

as the glands of Skene and Bartholin, or the ^ 

of the eervix or the deep intricate plicae of the ^ ^ 

organisms find their ideal habitat. According y, ese 
moil "harbors of infection” of the gonococcus m the ^3 

In spite of prevalent misconccptioM to the con 
faithful to its baoteriologic characteristics in the im 

374 




SCHAXIPPLER APID KtSHN : GOKORRHKA dl» 

tract. Its pathogenic action on the genital apparatus in female infants 
and small children is not due, as has been urged, to chairges in its bac- 
teriologic properties, or to an hypothetical low resistance of invaded tis- 
sues. It is due to mechanical and developmental differences between the 
immature and mature female genitalia. These differences are sufficiently 
obvious, but have not heretofore been given the emphasis which they de- 
serve in this connection. They may be summarized as f ollou s : 



Fig. 2-A. — Microphotograph ‘bC complete sagittal section of uterus and vagina of 
stillborn infant, formalin hardened ; e.c. endometrial cavity ; v. vagina : c. cervix. Note 
complete absence of cervical glands and rudimentary nature of endometrial glands. 
Note also complicated cryptiform vaginal structure, less marked in this specimen than 
in the average, due to postmortem mechanical distention for purposes of study. Note 
folds or pleats over entire vaginal cervix. 



Fig. 2-B. — High power of area outlined in Fig. 2-j 
V. vagina. The entire endocervix is included in this arei 
persistent squamous epithelium at external os, also pleat 


c. cervix; e.o. external os; 
Note absence of glands and 
or folds on vaginal cervix. 


^ 1. The glands of Skene, while they may be noted in a rudimentary form 
m very early stages of development, do not achieve sufficient complexity 
to become “harbors of inf ection ” until the approach to puberty or later 
2. Similarly, the Bartholin's glands, while they may be noted in a 
rudimentary form as early as the sixth month, do not develop characteris- 
tics favorable to the growth of the gonococcus short of fairly complete 
geneial sexual development^' (see Fig. 1-A B) 

are V theseTtrurtwIs Ti? emh 'a the literature (whicli 




o. — Siiiflttul Fpotion of block ineludins: bladder, urethra, uterus, cervix and 
vanilla of full-term stillboni female infant. The intricate cryptiform accordion-like 
conformation of the vagina is ciearly shown. At points h the walls are spread to 
demonstrate tlio deep longitudinal plicae of tlie lower vagina. The relative occlusion 
of the hymeneal orllico is sliown at a. Mote the dennite plications on the vaginal cervix 
.similar to tlio.so of tiie upper vagina. 


Pig. 4-A.—Harmless efficient vaginal d'stention obtained by autW 
muth subcarbonate (25 per cent) incorporated in the usual ointment base, 
ten years. 




SCHAUFFIvER AKD‘ KUHN : GONORRHEA 


377 


3. Tlie racemose glandular system of tlie endocervix is very tardy in 
development, frequently being apparent only as scattered rudimentary, 
blunt, glandular crypts, up to as late as the fifteenth year (see Fig- 
2-A,B). 



Fig. 4-B. — Same patient as Fig. 4-A three minutes later. Tlie tube has been removed 
showing that the heavy ointment base maintains the distention and is well retained. 




378 


A^IERICAX JOURNAL OF OBSTETRICS AND GYNECOLOGY 


4. The immature vagina is merely a potential cavity held in a state of 
constant closure by its elastic and muscular coat, and replete vrith stag- 
nant crypts and rugae. Its walls are held tenaciously’’ approximated, 
much as are ^Yet paper surfaces— this in marked contrast to the flattened 
gaping vagina of the parous adult (see Fig. 3). 

The conclusions to be gained from these observations are obvious and 
can be summarized : 

1. Since the rudimentary Skene’s glands of the immature individual 
offer no harbor of infection, it is not to be expected that infection of clini- 
cal importance by the gonococcus ivill occur. This is borne out by clinical 
experience. 

2. The same is true in the case of the immature Bartholin’s glands 
(Fig. 1). 

3. Not only is the immature endocervix practically never infected by 
the gonococcus, for the reason that the cervical glands are not present in a 
form to harbor the organisms (Pig. 2) but also, a high degree of immunity 
is granted through this agency to the endometrium and fallopian tubes. 
It is my belief that in the immunity of the immature endocervix to gonor- 
rheal infection, we haA’e a satisfactory explanation of the singularly low 
incidence of salpingitis due to vaginal gonorrhea in the immature. 

4. The contracted cryptiform rugeose vagina of the immature indi- 
vidual constitues ^^rtually an ideal “harbor of infection” (Pig. 3). In 
this factor we have a perfectly satisfactory explanation of the occurrence 
of a primary vaginitis as the most risual manifestation of gonorrhea in the 
immature individual. In the adult, the distention and flattening of the 
vaginal wall with the frequent introduction of bacteria and other noxious 
agents, entirely alters the conditions favorable to the development of this 
organism. 

We know that, in the adult, the gonococcus is retained in the Skene’s 
and Bartholin’s and the cervical glands, and is frequently passed over 
from the cervical glands to the endosalpinx, while the vagina, except for a 
transient inflammatory reaction, is immune. We have shown that, on the 
other hand, in the infant and small child, the vagina is the point of elec- 
tion — the Skene’s, Bartholin’s, and endoeervical glands are relatively non- 
infectible, and there is immunity of the endosalpinx secondary to that of 
the endocervix. 

It is not sufficiently clearly understood, even by those who have made 
something of a study of gonorrheal infections in infants, that the vagiiial 
cervix is the seat of deep pleats and folds similar in all respects to those 
noted throughout the remainder of the vaginal wall (see Pig. 3-A, B), 
thus, the vaginal cervix is not exempt from an infection which involves the 
entire A’aginal wall. This fact was early noted by Hess in a series of post- 
mortem examinations. Unfortunately, Hess ’ observation has been miscon- 
strued. In his own report Hess carefully differentiates between the vag- 
inal cervix and the endocervix. He reports infections of the vaginal cer- 
vix only. He has been broadly quoted to the effect that at postmoitem le 



SCHATJFFLER AND KUHN : GONORRHEA 


370 


has demonstrated “cervical infections,” with the inference that endo- 
cervical infection has been described. This inference is not .instified. 



Fig. 5-A. — Injection by the method of Gellhorn and Stein, i. e., equal parts of warm 
vaseiine and lanolin (25 per cent bismuth) showing comparatively unsatisfactory dis- 
tention at height of Injection. Child of four yeai’s. 





380 


AMERICAN JOURNAL OF OUSTETRICS AND GYNECOLOGY 


The use of the term “cervico-vaginitis” to describe such infection, 
■while it is perliaps more minutely descriptive, we believe is misleading in 
that it suggests a frequent involvement of the endocervix as an accompani- 
ment of vaginal infections. Endocervical infection as an integral part of 



Fig. c 

tlie usual 
years. 


■A.— Injection per catheter ot opaque soluUon of sodium iodide wmparable to 
Instillation. The solution is obviously inefliclently distributed. Child of three 






SCHAUFPIiER AND KUHN : GONORRHEA 


381 


the pathology" occm’s only in individuals who have reached a stage of ad- 
vaneed development of the cervical glands. It is perhaps an occasional 
transient accompaniment of severe acute infection of the immature vagina. 

The use of the descriptive term “vulvovaginitis” is distinctly a mis- 
nomer. The vulvar irritation in these cases is completelj’’ secondary , and 
due to factors similar to those which cause external irritation in pyelitis, 
diarrhea, etc. 

INDICATIONS FOR Rx^TIONAL TREATMENT 


Douches, instillations, injections, etc., have been used empirically and in- 
effectually for too many years. These timeworn measures, mildly effective 
in certain adult involvements, are grossly inadequate to meet the existing 
indications in any but virtually self -limited cases. The need is for the uni- 
versal application to the affected area of a reliable antiseptic over a pro- 
longed period of time. Gelhorn and Stein contributed conspicuously in in- 
augurating vaginal treatment by the use of an ointment incorporating an 
antiseptic which was injected per catheter in a softened state. The most 
effective approach to these indications is achieved, however, through the 
use of a relatively firm ointment base, injected by a technic which insures 
the production of sufficient intravaginal pressure to cause invasion of the 
ointment into every crypt and corner. The use of plain anhydrous lanolin 
incorporating an appropriate concentration of any worthwhile antiseptic 
is advised. ("We use one per cent silver nitrate.) The ointment should 
not be warm, as its quality of firmness facilitates distention of the vagina 
with the use of mild intravaginal pressure. Also, it is more easily and com- 
pletely retained if cold, and has the highest possible fluid affinity, which 
makes it a highly effective vehicle for carrying the antiseptic into the moist 
vaginal wall — this in contrast to the usual vaseline base which is repulsed 
by moisture. 

Our clinical studies have been supplemented by the injection of post- 
mortem specimens by this technic. Clinically, x-ray visualization of the 
vaginal cavity has been made possible by the employment of opaque media. 
Using this procedure, we have studied all types of treatment (see Pig. 4, 
5, 6). By the method described we have obtained a consistent, complete 
and satisfactory application of the medicament, which remains in the 
vagina over periods varying up to forty-eight hours. This has not been the 
case with other methods conscientiously employed. The use of this method 
in over 2000 treatments has in no instance resulted in any untoward inci- 
dent of any sort whatsoever. 


The results of the use of this method have shown a surprising and sat- 
isfying improvement over other methods in a large series of stubborn cases 
m the majority of which several other methods had failed. It is simple ra’ 
tional, harmless, and effective. ■ ^>impie, la- 


Note; Further clinical considerations with reference to the or.r,r <.• i. 
method and detailed instructions in technic may be found in tl ^ 
of Diseases of Children, Vol. 34 Oct 1907 ^r,44 r-r ^ American Journal 

350-355. ’ ’ 43, Feb., 1932, pp. 



y SPONTANEOl'S EVOLUTION OP THE FETUS IN TRANSVERSE 

PRESENTATION 


Ntciioi,rox J. Easthax, M.D., Baltimore, j\Id. 

(Irnm the Depart ment of Obxtetrics, The Johnx ITophins Hoxpital and University) 

'T'HE ])henomenoii of spontaneous evolution of tlie fetus from trans- 
verse lU’esentation has been one of unusual interest to obstetricians 
for various reasons. In the fii’st place, it is an exceedingly rare event, 
occurring possibly once in 5,000 labors; secondly, it exemplifies nicely 
■\vliat the natural lorees of labor may occasionally accomplish when con- 
fronted with a seemingly insuperable obstacle; thirdly, it represents the 
most complicated mechani.sm of labor; and finally, its beginning stages 
may bo recognized in almost cvciy case of impacted transverse presenta- 
tion. so that wo may regard the latter entity as an example of unsuccess- 
ful sjmntancous evolution, just as we consider transverse arrest of the 
occiput as an incomplete stage in the mechanism of occiput posterior 
positions. 


The process of spont.'nicous evolution 'vv.os first luentioiicd by Denman in 17S5, but 
w.ns not .oceur.'itely (le.scribcd until 1819, when Doiigl.ns published his minutely ex- 
id.anntory study based on seven personal cases. Since the reports of these two ob- 
servers differed considerably, it has been generally assumed that there must be two 
distinct mechanisms responsible for spontaneous delivery in these cases, the one being 
designated as the mechanism of Denman and the other ns the mechanism of Douglas. 
In 1915, Stephenson, with the collaboration of the late Dr. Williams, made a study of 
the original papers of these author.s, pointed out that the description of Denman was 
exceedingly casual and inaccurate and, after describing two eases himself, reached the 
conclusion that there is but one mechanism of spontaneous evolution, the one de- 
scribed by Douglas. 

Observations made in this Clinic upon three additional eases seem to 
throw further liglit on this problem and have prompted this report. 

In all, five instanc6s of spontaneous evolution of the fetus have been 
observed here among 147 consecutive cases of transverse presentation, an 
incidence of 3.4 per cent. This figure is slightlj’ higher tJian is usually 
reported, Pranque having observed the phenomenon in 2.5 per cent of 
his eases, while Zangemeister found only three cases in his series of 232 
transverse presentations, an incidence of 1.3 per cent. Tlie histories of 
our five cases follow. 

Case 1. — The patient was a thirty-tlivee-year-old, colored multipara, para ix, her 
previous pregnancies having terminated spontaneously under the care eitiiei of mid 
wives or private physicians. Her last period had occurred .Tanuarj 18, 1930. She 
was admitted to the hospital on August 19, 1930, after 43 hours of labor at home, 
the membranes having ruptured 29 hours before admission. Upon examination the 
right arm was found macerated and prolapsed into the vagina, while the right 
shoulder was tightly impacted in the pelvis. No fetal heart sounds were audib e. 
Shortly after admission, during a strong uterine contraction, the fetus could be seen 

382 



EASTMAN ; TRANSVERSE PRESENTATION 


383 


to descend, the posterior aspect of the right shonldor, the f J 
nppev right side of the thorax coming into view. Then, mth a rotating nation the 
. luiiar region and the breech appeared, folloived by the loiver extremities Pmal j , 
with the aid of slight traction and moderate suprapubic pressure, the left aim a d 

liead were easily delivered. 

The fetus, which was stillborn and macerated, weighed 2600 grams and measured 
49 cm. in length with a crown-rump length of 34 cm. The head, which was gieat j 
distorted, lay flattened against the trnnh, being bent on the elongated neck sharp y 


to the left. 

The placenta was delivered spontaneously. After a febrile course, the patient was 
discharged well on the thirteenth day postpartum. On discharge examination, she 
was found to have a generally contracted, funnel pelvis, the diagonal conjugate 
measuring II .0 cm. and the outlet diameter 7.5 cm. 

Case 2. — The patient was a twenty-three-j’ear-old, colored multijiara, whose one 
previous pregnancy had terminated spontaneously. Her last menstrual period had 
occurred on June 20, 1922. When admitted to the hospital on February 10, 1923, she 
was in beginning labor with a small baby lying in transverse presentation, the fetal 
heart sounds audible. After seven and one-half hours of labor, it was found that 
the membranes were bulging through the introitus and preparations were made to 
rupture them and follow this with version and extraction. Before this could be done, 
however, the left arm and shoulder prolapsed. With the next pain the back, which 
had been directed toward the rectum, rotated anteriorly and at the same time be- 
came bent upon itself in such a manner that its convex aspect was directed toward 
the maternal sacrum. This permitted the breech to be born, followed by the lumbar 
region and legs. The head now rotated so that the occiput was directed anteriorly 
and was readily delivered with the aid of slight traction. The entire procedure, from 
the time the slioulder appeared at the outlet until the head was born, required a pe- 
riod of less than three minutes. 

The fetus, which was stillborn, weighed 1750 grams. Its length was 42.5 cm. with 
a crown-rump length of 28 cm. The mother, w'hose puerperium was uneventful, w-as 
discharged well on the fourteenth day of the puerperium. Her Wassermann reaction, 
however, was positive. 


Case 3. — The patient was a twentj’-five-year-old colored multipara, para v, the 
previous pregnancies having all terminated spontaneously. Her last menstrual pe- 
riod had occurred on August 24, 1911. When she was admitted to the hospital on 
April 30, 1912, a small child was found in transverse presentation; the fetal heart 
sounds were not audible. After ten hours of labor, the membranes ruptured at com- 
plete cervical dilatation, and at the same time the right arm prolapsed. With the 
next pain the shoulder came into view, followed by the back, breech and lower ex- 
tremities. The left arm and head were readily delivered by means of slight traction. 

The fetus weighed 2010 grams and measured 47 cm. in length. The mother sub- 
sequently died of puerperal infection. 

Case 4,— The patient was a twenty-seven-yenr-old, white multipara, who was de- 
hvered of a 2690 gram, stillborn fetus, by spontaneous evolution after seven and one- 
half hours of labor. (Beported in detail by Stephenson.) 

Case 5.— The patient was a Mventy-six-year-old colored multipara, who was de- 
nered of a 2500 gram, stillborn fetus, by spontaneous evolution after twenty-six 
hours of labor. (Reported in detail by Stephenson.) ^ 

It be noted that the smallest infant in the group weio-hed 1750 

babies bom by spontaneons evolution fall. Spontaneous delivery of 
fetuses Mmglnng less than 1500 grams is not uLommon in IraZrse 



384 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


presentation, but in tliose instances delivery is usually effected not by 
the mechanism of spontaneous evolution, but by the simpler process of 
conduplieato corpore. On the other hand, infants weighing over 2700 
grams arc usually too large to undergo the compression necessitated by 
spontaneous evolution, although a few exceptional cases are on record 
in which the child exceeded 3000 grams. (Busch, 3500 grams; Klein- 
wachter, 3020 grams; Herrgott, 3300 grams.) It seems of interest also 
to note that in three of our live cases, the duration of labor was less 
than 10 hours ; moreover, it was observed repeatedly that once the process 
had begun, it was completed with great rapidity, so that, as in Case 2, the 
entire procedui’e from the time the shoulder appeared at the outlet until 
the head was horn, required less than three minutes. 

Turning now to the question of the Denman and Douglas mechanisms, 
it must be recalled that during the past hundred years, German ob- 
stetricians have reported, collectively, a large number of cases of spon- 
taneous evolution, and in each instance apparently have been able to dis- 
tinguish between the two mechanisms and to classifj’' their cases accord- 
ingly. Moreover, Stephenson himself, in describing liis first case, ob- 
serves that “the position of the buttocks is very unusual, is particularly 
difficult of explanation, and seriously complicates the classification”; 
and he concludes that “it would appear best to classify it as an instance 
of an abnormal or complicated Douglas mechanism.” From these facts 
it is apparent that the process of spontaneous evolution presents suffi- 
cient variation to give the semblance, at least, of two distinct mechanisms. 
The alleged difference between the two processes seems to center on the 
fact that in one of them the breech appears immediately after the pro- 
lapsed shoulder (the mechanism of Denman), while in the other the 
lateral aspect of the thora.x follows the prolapsed shoulder, the breech 
being deliAmred only after the thorax as well as the abdomen have been 
extruded (the mechanism of Douglas). Concerning the intrinsic mech- 
anism responsible for the expulsion of the fetal parts in this or that order, 
the literature offers only vague and contradictory explanations. From a 
study of the five eases described in this report, we believe that some de- 
gree of clarity might be gained if the two apparently different processes 
of spontaneous evolution were considered in the following manner; 

Mechanism No. 1 . — Following tlie prolapse of one arm, tlie corresponding shoulder 
and scapular region are forcibly driven into the pelvis by uterine contractions. Since, 
under these circumstances, there is no room in the true pelvis and little in the false 
pelvis for an object as large as the fetal head, the latter remains stationary with the 
result that the neck becomes elongated. These conditions are shown in Fig. 2. The 
crucial process now takes place; namely, an extreme lateral flexion of the spinal 
column due to downward pressure on the buttocks, so tliat tlie latter are forced down 
beyond the shoulder and expelled. A moment’s consideration of Fig. 2 will make it 
clear that this lateral flexion may occur in one of two directions the breech may be 
forced either toward or away from the prolapsed arm. In the specific case shown 
in the drawing, the fetus is represented as lying in the posterior half of the uterus, 
so that the specimen is viewed from the front. Now, if the breech in this case is 



EASTMAN: TRANSVERSE PRESENTATION 


385 


driven down towards the prolapsed arm (the convex aspect of the hent spinal colmnn 
being directed toward the maternal sacrum), the buttochs will be born ^ 

after the prolapsed arm not only because the lateral flexion of the trunk will produce 
a certain drawing up of the prolapsed shoulder but also because the descending 
breech will tend to hide the lateral aspect of the infant’s thorax from view. This 
process we are designating temporarily as mechanism No. 1, and believe that it is 
characterized essentially by the fact that the buttocks are driven down in the direc- 
tion of the prolapsed arm, the breech necessarily being expelled before the lateral 
aspect of the thorax appeai-s. This mechanism, it would appear, is the one usually 
designated by the name of Denman, hut since that author reported only that the 
“breech and inferior extremities are expelled before the head,” it seems hardly 


justifiable, as pointed out by Stephenson, to attach his name to it. 

Mechanism No. S . — ^This process of spontaneous evolution, in our opinion, differs 
from the one just described in that here the buttocks are forced down in the direc- 
tion of the shoulder which is not prolapsed, with the result that the convex aspect 
of the arched trunk necessarily protrudes through tlie maternal vulva, followed by 
the lateral wall of the abdomen and finally the breech. This mechanism has quite 
rightly been given the eponym of Douglas, who emphasized the fact that in his cases 
the side of the infant ’s thorax was born before the breech. 


For the sake of clarity, we have considered the process of spontaneous 
evolution as exhibiting two separate and distinct mechanisms. It must 
be apparent, however, that various gradations will exist in the mech- 
anisms as described, depending on whether the flexion of the spinal 
column is directly lateral or only partly so •, and for this reason it seems 
more logical to presume that we are dealing with variations of but one 
mechanism, an extreme lateral flexion of the fetal back. The precise 
order in which the fetal parts are born becomes then a secondary matter, 
dependent upon the direction which this flexion assumes in relation to 
the prolapsed shoulder. 


While our acquaintance with the latei’ stages of spontaneous evolu- 
tion is based upon many careful observations of the process, our exact 
Imowledge of its earlier stages is founded chiefly upon a few rare cases 
in which the mothers have died while the process was under way and in 
which frozen sections have been made of the maternal torso 'in such a 
way as to show the exact relationships of the fetal parts. Such a case 
was Chiari’s, reported in 3878. Since in this country, at least, it will be 
rarely, if ever, possible to obtain such specimens, it has seemed worth 
while to make similar studies on eases in which the fetus was in the early 
stage of spontaneous .evolution and in which the uterus was removed 
unopened. The specimens from two such cases are shown in Fi^s. 1 and 

h a unopened uterus with the fetus in situ was 

aidened for a suitable period in formalin and was then carefully opened 

by ar'a^ clyaw/toTde 

Brief histories of these two cases follow. 

i. .™sve„e LT™ SMX tl'i t/S 



386 


AI^IEinCAN JOUKNAE OF OBSTETRICS AXD GYNECOLOGY 


only 3 eni. dilated despite the fact tliat an intrauterine bag bad been in place during 
tbo previous twelve hours. At tliis time, the patient’s temperature was 101.6° and 
her pulse 130, while the fetal heart was no longer audible. In view of the evident 
intrapartum infection it was decided to removo the bag and perform hysterectomy 
on the unopened uterus. This was done, a loop of cord prolajising as the bag was 
taken out. The mother was discharged from the hospital on the twenty-fifth day 
postpartum after a febrile convalescence. 

The amputated uterus, which presented a trefoil shape with its greatest diameter 
transverse, measured '21 by 20 by 17 cm. The cervix was 2.5 cm. in diameter and 
was occupied 1)3’ a loop of cord. 

The conditions found upon opening the uterus arc .shown in the illustration. The 
male child weighed 2000 grams and was compressed into a triangular mass 10 cm. 



wide, 10 cm. long and 11 cm. tl.iek. Us loft sldo lay 

compressed as to occupy the smallest possible space. le m 3 1 . oggetl on one 
so Li the face was in contact with the knees and feet, which were ciossed 01 on 

another. The left arm was flexed with the entire Z 

space between the thighs and face. The shouldci conditions 

of the left knee, the upper pole of the specimen. On the g circum- 

were essentially the same, except that the region oiei le ngi ^ ^ “caput 

scribed over an area of 10 cm., was somewhat of this 

succedaneum.” It should be noted that the right aciomium 

While the placentation was normal, sections ^t^ 

showed inflammation of the the chorionic connective tissue 

a process that occurred even in the tuiiaai 1 
both streptococci and bacilli were demonstrable. 



EASTMAN; TKANSA^KSE PRESENTATION 


387 


Fig. 2. — Tlio patient was a twentj-eiglit-year-olcl colored multipara, 'wlio liad not 
been registered on the service. Her membranes ruptured prematurely, labor ensuing 
in about twelve hours. After twenty hours of labor at home, where one or more 
vaginal examinations had been made by a private physician, she was admitted to the 
hospital with a temperature of 103.8° and a pulse ranging between 150 and 180. 
Examination showed that the uterus was tetanieally contracted around a small child 
in transverse presentation, rvhose right arm was prolapsed into the vagina ; the fetal 



livered by hJster?ctomy mrthe HleZat^T ^ 

moHier died immediately after the operation * ” ^etus. T 

- the plm.o Of the tubal insmJons, whrTirr^T^" ^ 

m' «‘e head occnpvinff as found that the child lay 

p- - I “‘,?s 




388 


A.JIEritCAX JOURICAL OF OBSTETRICS AND GYNECOLOGY 


base of the neck was in contact with the right, and the right side of the tiiorax with 
the left aspect of the internal os. 

The fetus was as closely packed as possible, and it was apparent that every trace 
of aniniotic fluid had escaped. Nowhere was there any evidence of a contraction 
ring, the thickest part of the uterus, indeed, corresponding to the lower segment, 
uliilo its thinnest part was above the tubal insertions. Microscopic studies of the 
uterus showed a fulminant, ascending infection. 

In conclusion, the wi-iter wishes to acknowledge his indebtedness to 
the late Dr. 'Williams for his advice and his active assistance throughout 
this study. 

REFERENCES 

Busch; Geburtsh. Abhandl. Marburg, p. 73, 1826. Chiari: La Evoluz. spontan. 
- e. c. Milan, 1878. Denman; London M. J. 5: 64-70 and 301-309, 1785. Douglas; 
An Explanation of the Real Process of the Spontaneous Evolution of the Petus, etc., 
Dublin, 1819. Franque; Winckel’s Handbueh der Geburtshilfe 2: 1612, 1905. 
Herrgott; Ann. de gyn. et d’obst. 13; 193, 1918. Klcintvachicr ; Arch. f. Gyniik. 
2; 112, 1871. Stephenson; Bull. Johns Hopkins Hosp. 26: 331, 1915. Zange- 
mcistcr; Mechanik und Therapic der in dor Austreibungsperiode befindlichen Quer- 
lagen, Leipzig, 1908. 


POSTMENOPAUSAL BLEEDING 
Samuel H. Geist, M.D., and Morris jILvtus, M.D., New York, N. Y. 

(From the Gynecological Service and Laboratories of Mount Sinai Sospital) 

W ITHIN the past few years a new impetus has been given to the 
study of po'stmenopausal bleeding. 'While it is true that in the 
majority of cases a malignant neoplasm is the etiologic factor, it has been 
pointed out that in a large group of cases, lesions both inflammatory or 
of benign neoplastic nature may be the undei’lying causes. A statistical 
study comparing the etiologic factor as malignant or not malignant, and 
the relative pi’oportioii of the two groups is interesting and instructive, 
but the more important aspect is the one dealing with the pathologic 
physiology. The appearance of uterine bleeding, associated with a non- 
ulcerative lesion, from a mucosa that is no longer sensitized and no longer 
undergoes a cycle because of the exhaustion of the ovarian function is a 
fascinating but still unsolved phenomenon. 

Moulonget and Doleris published 7 cases of ovari-an tumors with postmenopausal 
bleeding. In 2 cases there was present an hypertrophy of the mucosa, associated in 
1 with an endometrial polyp. In 3 cases polyps only were present. One case of 
endometrial hypertrophy was associated with a granulosa cell tumor. 

Robert Meyer reported 7 cases of postmenopausal bleeding with ovarian tumors 
and hyperplasia of the uterine mucosa. In this series tliere was 1 fibroma, 1 round 
sarcoma, and 1 angiosarcoma. In addition there were 3 granulosa cell tumors and 
one folliculonia carcinomatodes. He suggested that the tumors per se, may have an 
endocrine function in the granulosa cell tj'pe, or may stimulate a latent ovarian func- 
tion in other types. 

Schiffman has published some important data on the subject of postmenopausal 
bleeding. By postmenopausal bleeding he means vaginal bleeding appearing one year 
after complete cessation of the regular menstrual period. He mentions numerous 
eases due to local ulcerative lesions, as decubitus ulcers in prolapse, carcinoma of the 



389 


GE)ST AKD MATUS: POSTMENOPAUSAL BLEEDING 


, Tinlvnq He is also inclined to attribute 

troman seventy-two years old, who thirty-two years after the menopause, had In d 
episodes of vaginal bleeding associated with a mucoid carcinoma of the ovary. 
Believes that the first symptom of carcinoma may he bleeding. . • 

M. n ! wZ’ 

(.2) bleeding earned by earpas lesions, and (S) bleeding eansed by indefinite lesions. 




In Groups „ and 3 he had 51 cases; 2 niyom.ss and polyps; 11 polyps; 14 fundal 
carcinomata; 8 ovarian carcinomata, and 16 not defined. He accepts the presence of 
po i ps as a tiue etiologic factor. The proportion of ovarian carcinomata, 16 per 
cent IS quite imposing. He concludes that if curettage in an indefinite ease shows 

Z muco-sa is obtained and 

parotomj should be done. If an ovarian enlargement exists surely operate. 




390 


a:merican journal ok obstetrics and gynecology 


Laliiii, reports n ease of earcinoina of the ovary and a corpus luteuin cyst. He too 
believes that the tumor may have an endocrine function or may stimulate the ovary 
even after the menopause. 

Benthin in an excellent article finds CO per cent of postclimacteric bleeding benign. 
In only 10 per cent of the cases of corporal bleeding, postjnenopausal, is the underly- 
ing lesion malignant. 

lie too divides the benign cases into three groups. (1) Inflammatory; (2) pol 3 ’ps; 
and (3) negative. 

In the first group the histor\- is one of a bloodj' vaginal discharge for a long pe- 
riod. Most patients are well along in the menopause. Bj- curettage one obtains a 
little nnieosal tissue some with necrosis and inflammatory infiltration. This simple 
operative procedure is curative. 

In the second group, twenty-five per cent of all the cases, there is usually a history 
of sudden bleeding with no previous hemorrhagic discharge. The uterus is large. 
There is no relation between the size of the polyps and the amount of bleeding. 

In the third class he groups the ovarian tumor.s, which he believes are purely co- 
incidental lesions. He stresses the rfde played bj- arteriosclerosis. 

lu addition to llte above-mentioned articles, a nvnnbev of other papers 
liave appeared. There have been jjublieations dealing with the etiologic 
factors in this t 3 ’pe of bleeding and much speculation on the meehanisin 
of postmenopausal hemorrhages. The references to these articles will be 
found at the end of the paper. 


Tablr I, Beniox Lesion’S Associated IViTn SIenopausae Bleeding 



1 

1 

1 

§ 

p 

SB 

o 

K W 

OVARIAN CYSTS 

POLYPS 

w 

o 

?? 

o 

55 

m 

Q 

<5 

ovarian 

IIALTONANCY 

FIBROIDS 

S M 

o § 

< fe 

o o 

CARCINOMA 

OF FUNDUS 

2 

6 B 
o 53 

^ o 

ST ^ 
pH P 

Ph 

< o 

CO o 

Polj’ps 

Fibroids 
Adenomjmsis 
Ovarian Tumor 
benign 
Negative 
Endometritis 
and 

Endocervitis 

Hj'pertropliic 

Endometrium 

1 

1 

3 

1 

3 

o 

1" 

! 

■ 

m 

1 

1 

o 

2 

2 

1" 

3 

3 

1“ 

1” 

2“ 

1 

1 


We have studied a series of eases and have found in a total of 182, that 
42 per cent were benign, of which 10 cases were benign ovarian lesions, 
the remaining 68 were benign cervical or uterine conditions. Some of 
these lesions were associated with benign lesions in other portions of the 
generative tract. 

In the total number of benign lesions of the cervix and fundus we 
found a wide variety’ of conditions (Table I). We have not tabulated the 
eases due to systemic disease. 

The histories of the cases (Table II) showed no differential chaiacter- 




















GEIST ANP MATUS: POSTMENOPAUSAL BLEEDING 


391 


istic except that after a definite period of physiologic menopause ranging 
from one year to twenty years tJie patient was admitted to the hospital 
complaining of vaginal bleeding either in the nature of intermittent or 
continuous spotting or bleeding of from two days’ to two years duration. 
At times the bleeding was described either as profuse or scanty, at times 
associated with clots. Physical examination, curettage or laparotomy 
revealed the benign nature of the lesion and a subsequent period of ob- 
servation, over a period of one year, demonstrated that the patient re- 
mained cured. 


Table II. Benign Lesions and Susimaey of Symptoms 



NO. 

age 

MENOPAUSE 

DURATION 

BLEEDING AND 

SPOTTING 

Polyps 

Hypertrophic 

29 

1 

52-70 yr. 

1 to 21 yr. 

1 week to 2 years 

Endometrium 

10 

46-67 yr. 

6 to 20 yr. 

Profuse-Constant 

1 week to 3 montlis 

Eibroids 

1 15 

50-62 yr. 

1 to 12 yr. 

Moderate-Scant}' 

1-6 mouths 

Adenomyosis 

3 

50-57 yr. 

1 to 1% yr. 

Profuse and Scanty 

1 week to 1^ months 

Ovarian Tumors benign 

■*.> . ' 

11 

45-70 yr. 

1 to 20 yr. • 

1 

1 

Sliglit-Profuse 

1 week to 2 months 

Negative 

Endometritis and 

13 

44-68 yr. 

1 to 29 yr. 

Slight 1 week 

Endocervitis 

11 

46-66 yr. 

1^ to 20 yr. 

Spotting 1-2 weeks 


Hieie were 29 cases of cervical adenomatous or fibroadenomatous 
polyps. Of these eases six were associated with benign lesions of the 
uterus (Fig. 3), or ovaries which may have been the dominant factor in 
the causation of the bleeding. The duration of the menopause was from 
one year to twenty-one years. The bleeding was the only symptom and 
was described as a spotting, intermittent or continuous, varying from one 

day to two years’ duration. The removal of the typical adenomatous 
polyps cured the patient. 


In one instance, a patient of Dr. Edward Bleyer’s, the history aDd subsequent 


moral of the polyp. ^ P05>tmenopausal, was cured by re 

In ta h..ta„ce. exa„™a,i„„ failed to teveal any leaion other than 






392 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


liypcrtvopliiecl endometrium, except for the presence of an adenomatous 
polyp in one case. In these cases the ages varied from forty-six years of 
age with a menopause duration of six years to sixty-seven years of age 
with a menopause duration of twenty years. 

The histories here were sliglitly different from the polyp type in that 
the bleeding was more constant, more profuse, and in one instance de- 
scribed as being marked with large clots. The duration was from one 
week to three months. In this group evidently the bleeding, in contra- 
distinction to the eases with cervical polyps only, was too profuse to 
neglect for a long period of time. A curettage with a diagnosis of hyper- 
trophied endometrium, a negative physical examination and symptomatic 
cure for a period of over a year leads to the natural conclusion that this 
benign lesion W’as the factor associated with bleeding. AVhat is the cause 



Fig. 3. — Uterine mucosa showing hyperplasia associated w 
polyp in a postmenopausal bleeding case sixty-four years 
postmenopausal. 


ith fibromatous cervical 
old and twenty years 


of this hypertrophy is purely speculath'e. A reawakening of the ovarian 
function, a vicarious action on the mucosa from some other ductless 
gland, some local stimulation to the endometrium with subsequent bleed- 
ing, all may be offered as hypotheses with no definite proof. IIHiy a 
curettage relieves these eases and not those occurring before the meno- 
pause is impossible to answer. 

Fifteen cases of fibroids, in six instances associated with other lesions 
that might be regarded as possible causal agents were studied (Fig. 4) . 
In two cases ovarian cysts, one a dermoid, one a simple cyst, wei e present. 
In one a benign polyp of the cervix existed. In one an adenomyosis of 
uterus, and in two malignant tumors one of the ovary and one of the tu e 
were found. Here the menopause had existed fi'om one to twelve years. 
The bleeding was reported as moderate or scanty, as persistent oi inter 
mittent, and in duration from one day to six months. Ej’^steieetomy was 


GEIST and MATUS; POSTAl-ENOPATJSAD BLNEDING 


393 


to as the physical examination made it dear that a tumor, the 
exact nature of which could not be determined, was present. Here again 
the question of the mechanism of the bleeding was not clear. JS as it due 
to pressure, erosion, congestion or a reawakening of some aten en ocri 

^'"in tiiree instances of adenomyosis there were associated lesions that 
might have been important factors. In these cases the ages were fifty- 
seven, fifty-five, fifty, the menopause 5 years, ^ 11/2 years, and 1 yeai re- 
spectively The bleeding in the one ease associated with fibroid, cyst and 
carcinoma of tube was profuse. Staining irregular for two days on three 
occasions over a period of H/s years was the history in the case associ- 
ated with an adenomatous polyp. In the third case, a patient fifty years 
of age with a menopause duration of one year, giving a histoiy of profuse 



Fig. 4. — ^Hypertrophied endometrium associated with fibroids in a postmenopausal 
bleeding case fifty-one years old and two years postmenopausal bleeding-. 


bleeding for one week, had an adenomatous polyp associated with the 
fibroid. The eases were cured by operation. 

In eleven instances of benign ovarian tumors, three were dermoids. 
One associated with a salpingo-oophoritis, one associated with a fibroid 
suhserous in cliaracter, and one associated with fibroid, adenomyosis and 
a primaiy carcinoma of the left tube. The ages here were forty-five, 
fifty-three, and fifty-seven, the menopause one and one-half years, four 
years and five years, respectively. Two of the cases, the one associated 
with fibroid and the one with a salpingo-oophoritis had slight bleeding 
for eight years in one case, and for two weeks in the second, while the 
case associated with the fibroid, adenomyositis and primary tubal car- 
cinoma had a history of bleeding on two occasions, six months and two 
months ago, for a few days and profuse bleeding with cramps two weeks 

bleeding permits of many hypotheses none 

01 wnicli can be proved. 



394 


AMERICAN' JOURNAL OF OBSTETRICS AND GYNECOLOGY 


Of the eight other cases there were three simple cysts, one twisted, four 
pseudomucinous and one case noted as cystic ovaries. In four instances 
there were associated lesions. In three adenomatous cervical poljqii, one 
with a simple cyst and two with pseudomucinous cy.sts and in the fourth 
there was a. fibroid associated with a simple cyst. The ages varied from 
46 to 70 years, the menopause duration from one year to twentj’' years. 
7’he Jiistory in most instances was that of staining noticed only reeentl.v, 
except in the case with cj'stic ov.nrics, where seven days' bleeding occur- 
red on two occasions in two years. This case must be looked upon prob- 
ably as an incomplete menopause. One other case, a sixty-three-year-old 
woman with a menopause duration of eight j-cars gave a history of bleed- 
ing four weeks. At operation a pseudomucinous cyst was removed. 
This patient continued to bleed and Avas subsequently operated upon for 
a carcinoma of the fundus. It is important in a postmenopause bleeding 
case that presents a benign lesion and continues to bleed after the eradi- 
cation of the presumed benign etiologic factor, that the possibilitj- of a 
malignant condition of the gencratiA'c tract should be entertained. This 
Avas also illustrated in the case previously mentioned Avith an adenoma- 
tous polyp and ovarian carcinoma. 

Thirteen eases Avere found in Avhich it Avas impossible by physical ex- 
amination or curettage to find any le.sion (Fig. 1). The folloAA'-up as far 
as AAms possible to determine shoAved that these cases remained Avell. The 
ages varied from forty-four to sixty-eight years. The menopause dura- 
tion from one year to tAA'cnt.y-ninc years. The bleeding in most instances 
Avas described as scanty for a day or tAA'o and in scA'cral instances as a 
slightly bloody dischai’ge. In one it AA'as only noted postcoital. Two of 
these cases could be dismissed as incomplete menopause and Iaa'o had a 
senile colpitis. The endometrium obtained by curettage in all instances 
Avas negative, in most of the cases being A'Cry scanty in amount, and re- 
lAorted atrophic or normal. 

In eleven instances inflammatory processes Avere the lesions associated 
Avith the bleeding. In three the diagnosis of pyometra and inflamed 
corporeal or cervical mucosa Avas made. The ages Amried from fifty-six to 
sixty-six. The menopause duration Avas one and one-half to twenty years. 
The bleeding Avas in the nature of spotting, in most instances of short 
duration. Here, too, curettage re.sulted in cures as aa'^cH as could be de- 
termined. Of course, the basic inflammatoiy change in the mucosa might 
readily explain the occurrence of bleeding. 

From the above it is evident that many lesions of benign nature (a 
number of considerable dignity, 42 per cent of our series of cases) can 
be associated Avith postmenopausal bleeding. 

In our series of postmenopausal bleeding, 57.5 per cent Avere malignant. 
There were 5 cases of carcinoma, of the Amlva or A'agina. In 37 cases, 
carcinoma of the cervix Avas present and in 41 cases, carcinoma of the 
fundus. Of the 15 malignant ovarian cases 3 Avere sai’comatous and 12 



395 


GEIST AI^D MA'TOS: 


POSTMENOPAUSAL BLEEDING 


carcinomatous, in one instance a fibroid was also 

tumors represented 14 per cent of tbe entire S^’o^P; ^ P« ^ 

wliole series being due to malignant ovarian tumors (Table III). 


Tablk in. malignant cases associated With PostmnnopausalBl^d^ 

5 

CciTciuomu of Vulva and Vagina 


Carcinoma of Cervix 
Carcinoma of Fundus 
Carcinoma of Ovary 
Sarcoma of Ovary 


37 

41 

la 

3 



Fig. 5. — Hypertropliied enUometrium associated with a spindle cell sarcoma in a case 
of postmenopausal bleeding fifty-five years of age and eight years postmenopausal. 

The ages varied from forty-four with a menopause duration of three 
j^ears, to sixty-five with a duration of fourteen years. The bleeding was • 
described usually as irregular spotting, or slight bleeding at intervals. 
In all instances a palpable tumor was present except in the one case re- 
ported to me by Dr. Edward Bleyer. 

In the case of sarcoma of the ovary, one spindle cell tumor was associ- 
ated with marked mucosal hypertrophy (Pig. 5) . 

In a case of primary carcinoma of the tube with bleeding five years 
after the menopause, the presence of adenomyosis and fibromyoma might 
account for the the bleeding as well as the possibility of bleeding from the 
tubal neoplasm with leakage through the ceiwix. The remaining group 
of carcinoma of the cervix and fundus require no especial mention as 
the bleeding associated with their presence is easily explained on the 
basis of an ulcerative lesion. 




396 


AMKinCAX JOURNAL OP OBSTETRICS AND GYNECOLOGY 


COMMENTS 

■\\ e can safely venture an explanation as to the etiologj^ of the bleeding 
in these postmenopausal cases in many instances. In the group of ulcera- 
tive lesions such as surface malignaney or carcinoma of the cervix or 
fundus, or angiomatous conditions, such as pol 3 'ps or inflammatory 
processes, the cause of the hemorrhagic discharge is evident. In the 
presence of large benign tumors pressure and the resultant change in 
the vascular architecture of the uterus may possiblj^ be a factor. 

In the cases where only a negative or normal mucosa was obtained 
(Fig. 1), in the absence of any local or constitutional disturbance, it is 
possible that the pituitary function is at fault. Fluhman has shown 
that there is an increase of the anterior pituitaiy hormone in the cir- 
culating blood after the menopause and Hartman has caused bleeding in 
castrates by the exhibition of anterior pituitaiy hormones. 

In those cases, however, in which benign hyperplasia of the mucosa of 
the uterus either as the onlj’’ lesion or associated with ovarian cysts or 
fibroids cause uterine bleeding we are led into the realm of conjecture 
and lypothesis. It is onl}’’ natural to drag into the explanation the rela- 
tion of ovarian function, mucosal lypcrplasias and coincidental bleeding 
(Figs. 2, 3, 4). In the cases associated with malignant ovarian tumors 
(Fig. 5) Mej'er and others have ascribed the bleeding to an endocrine 
function of the tumor itself or to a reawakening of the dormant ovary 
with a subsequent hypertroiily* of the mucosa of the uterus. 

Dr. Robert T, Frank in one case of medullaiy carcinoma of the ovary 
in a child of nine jmers found a large amount of female sex hormone in 
the tumor. Whether this same phenomenon is present in carcinomata in 
women past the menopause remains to be proved. If this is the case it 
"will corroborate the hj-potheses of Robert Mejmr, that the endocrine func- 
tion of the tumor itself is a factor in the postmenopausal bleeding associ- 
ated with malignant neoplasms of the ovaiy. 

In the small series of benign ovarian and uterine neoplasms associated 
with hypertrophied endometrium we did not find in the uterine discharge 
those elements which were previous^ described in other publications as 
characteristic of menstrual blood (Geist). It is possible that subsequent 
investigations may identify these cases as reawakening ovarian activity 
with menstrual bleeding of pathologic nature. This fact can be de- 
termined by proper investigation of the circulating blood for the presence 
of female sex hormone in the postmenopausal cases. Should this be 
present and should vaginal blood show the characteristic morphologic 
elements we would be in a position to state more definitely that the bleed- 
ing associated with a nonulcerative lesion was due to a process compar- 
able with the normal menstrual one, due to a reawakening of the dormant 
ovary or to the endocrine secretion of the tumor. 

To summarize, this stud}’" demonstrates: 



SAMUELS-EDLAVITCH ; ABDOMINAL HYSTERECTOMIES oy ( 

1. Postmenopausal bleeding may be due to either malignant or benign 

conditions. Benign, in a large group, 42 per cent. 

2. It emphasizes the importance of a proper follow-up in those cases 
especially, where after the removal of a benign condition, the bleeding 
persists. 

3. The iiaportanee of a study of the circulating blood and the tumor 
for the presence of hormones that may lead to a clearer understanding of 
the mechanism of the bleeding. 


BEPEBENCES 

Babes; Zentralbl. f. Gynak. p. 2639, 1926. Bmthin; Monatschr. f. Geburtscli. u. 
Gynak. 80: 117, 1928. Bukman: Arch, of Gynee. p. 135, 1929. Flatau ana Eerzog: 
Arch of Gynec. p. 127, 1926. Franhe: Zentralbl. f. Gynak. p. 9, January 5, 1929. 
Frankel; Arch. f. Gynak. 127-131; Zentralbl. f. Gynak. 1929. Fhihman, C. F.: Am. 
J. Obst. & Gynec. 18: 738, 1929; J. A. M. A. 93: 672, 1929. Geist: Am. J. Obst. 
& Gynec. 18: 321, 1929; Am. J. Obst. & Gynec. 22; 532, 1931. Granss: Arch. f. 
Gynak. 133, 1928. Ealhan; Wien. kiln. Wehnsehr. 18: 1925, 1925. Eartman, C. G., 
Firor, TV. M., and Gerling, E. M. K.: Am. J. Phys. 95: 662, 1930. Keller: Zentralbl. 
f. Gynak. No. 48, p. 3086, 1927. Lulin: Zentralbl. f. Gynak. p. 2743, 1927. Mandel- 
stann: Med. Welt, p. 1424, November 29, 1928. Menge: Zentralbl. f. Gynak. No. 43, 
1927. Meyer, M.; Zentralbl. f. Gynak. P. 30, p. 1663, 1925. Moulonguet, Eoleris: 
Gynec. and obst. 9H. 6, 1924. Mullerliein: Zentralbl. f. Gynak. March, 1928. New- 
man: Zentralbl. f. Gynak. No. 48, pp. 2695, 1925. Scliiffman: Arch. f. Gynak. V. 
138H. p. 339. Steinhart: Zentralbl. f. Gynak. No. 16, p. 98, 1929. Strauss; Am. J. 
Obst. & Gynec. 17; 250, 1929. Zweifel: Arch. f. Gynak. 137: 1008, 1929. 

100 East Seventy-Fourth Street. 


A CLINICAL PATHOLOGIC STUDY OP 303 CONSECUTIVE 
ABDOMINAL HYSTERECTOMIES 

A. Samuels, M.D., P.A.C.S., and E. S. Edhavitch, A.B., M.D., 

Baltimore, Md. 

(From the Gynecological Eepartment, Sinai Eospitalj 

'T'HIS study was made of all hysterectomy operations performed at the 
Sinai Hospital from July 1, 1926, to July 1, 1931. The operators were 
members of the gynecologic and surgical attending staffs and the 
surgical resident, whose work was closely supervised. 

Three hundred and twenty-three uteri were removed, of which 303, 
or 99.4 per cent, were excised by the abdominal route, and twenty, or 
0.6 per cent, by the vaginal route. All the patients were white; two 
hundred and thirteen (70 per cent) were on the private service, and 
ninety (30 per cent) were on the house service. Ninety per cent were 
married women ; 78 per cent of these patients having given birth to one 
or more children. The youngest patient in this series was a girl, seven- 
teen years of age, with a marked chronic pelvic inflammation; and the 
oldest, a woman, aged sixty-eight, with bilateral cancer of the ovaries 

Myomata and inflammatory disease were found in 79.5 per cent of the 
specimens examined in the pathologic laboratory. Myomata were pres- 
ent m 164 patents (54.1 per cent). The majority of these growths lere 



398 


AMEUICAN JOURNAL OP OBSTETRICS AND GVNECOCOGr 


of the multiple variety, in which niyoiuectoniy would have been impos- 
sible. Davis and Cusick in a questionnaire sent to leading gynecologists 
in liie United States and Canada, received answers wliich gave an aver- 
age of 71.6 per cent of all hysterectomies done for the removal of 
myomata. In tlieir .study of 335 patients who were hysterectomized in 
.six different hospitals in Detroit, they found that in 72.16 per cent of 
cases, the uterus was removed because of the jjresence of myomata. 

A.s the I'outine treatment for multiple fibromyomata at the Sinai 
Hospital is lij'sterectomy, the lower incidence may be explained on the 
basis that the hospital has no accommodations for the colored race, and 
tJie h'cquciiey of myomata in (he colored is a well recognized fact. 

JHalignancy of the uterus was observed in sixteen cases (5.28 per 
cent). Horwitz in a review of 1237 cases of primary cancer of the 
uterus at the hlayo Clinic, found only ten in Jewish women. He stated, 
after comparing the number of hospital admissions of Jewish and non- 
Jewisii patients at the Mayo Clinic, that cancer of the uterus was one- 
fourth as frequent in Jewish women. The occurrence of cancer of the 
uterus in 5.28 per cent of our series is in accord with the findings of 
Davis and Cusick who found in their study 6.09 per cent malignancies. 
The cervix was involved in five eases, and the fundus in ten cases. This 
finding is an unusual one, as most of the textbooks teach that cancer 
of the cervix occurs about eight times as frequently as cancer of the 
fundus. As three of the imticnts with cancer of the eeiwix and two with 
cancer of the fundus wore non-Jewish, our study shoAvs that cancer of 
tlie fundus occvirred four times as frequently as cancer of the cervix. 
Whether this indicates a greater immunity to cervical involvement or 
a greater susceptibility for tlie fundal site can only be conjectured. 
Further studies on this subject may yield interesting information. 

Table I shows the types of abdominal hysterectomies performed and 
the pathologic conditions necessitating the operation. Only 27 (8.91 
per cent) panhysterectomies were done, of which 50 per cent were pei- 


Table I. Type of Opep.ation 


DISEASE 

NO. 

Cancel- of tlie Cervix 

5 

Cancer of the Endometrium 

10 

Cancer of the Ovary 

5 

Myoma 1 

164 

Adeiiomyoiiia 

12 

Chronic Pelvic Inflammation 

77 

Pibrosis of the Uterns 

1 » 

Remaining Conditions 

21 

Total 

303 


SUBTOTAL 

nySTERECTOJIY 

TOTAL 

HYSTERECTOMT 

PER CENT 

0 

5 

100 

3 

7 

70 

3 

2 

40 

155 

9 


11 

1 

8.3 

75 

2 

2.5 

8 

21 

1 

ll.l 

276-91.09 

27 

S.91 



SAMUELS-EDL.A.VITCH : ABDOMINAL HYSTERECTOMIES 


399 


formed for malignant conditions. In the group of cancer of the endo- 
metrium, 3 subtotal hysterectomies were performed for some other 
condition and the diagnosis was made in the pathobgic laboratory the 
value of diagnostic curettage is emphasized by this finding, as all these 
patients complained of vaginal bleeding and curettage would have re- 
vealed the true pathology. Only nine (5.5 per cent) complete hyster- 
ectomies were performed in the myoma group. The simplicity of the 
subtotal operation and the increased mortality of the total operation in 
the hands of the less experienced may explain the low incidence of 
total hysterectomies in this study. This explanation probably holds 
also for the 2.5 per cent incidence of total operations for chronic pelvic 
inflammation. 


MORTALITY 


In this analysis of 303 consecutive abdominal hysterectomies, there 
were eight deaths, a mortality rate of 2.6 per cent. The subtotal hyster- 
ectomies numbered 276, with 7 deaths (2.5 per cent). The total death 
rate was 3.7 per cent. 

The incidence of 2.6 per cent mortality indicates the comparative 
safety of abdominal hysterectomies and compares very favorably with 
the results of other Class A hospitals. Davis and Cusick report a 
mortality percentage of 4.68 in their study and Burch and Burch report 
a mortality of 7.5 per cent in a series of 200 consecutive hysterectomies 
at the Vanderbilt University Hospital. 

Pulmonary embolism was the direct cause of death of two patients, 
both of whom had had a hysterectomy performed for multiple mjmmata. 
One patient died suddenly on the fifteenth postoperative day after a 
normal convalescence. Pathologic study of the uterus revealed a sarcoma 
of the wall. The second patient reacted well from the anesthetic and 
was considered in excellent condition until the fourth postoperative 
day, when, while sitting on the bedpan, she dropped over and succumbed 
within a few minutes. 

Two deaths in this series are attributed to shock. One patient, aged 
forty-one, had a subtotal hysterectomy for chronic pelvic inflammation. 
She became shocked on the operating table and never fully reacted in 
spite of vigorous therapy. Pulse and temperature were elevated and 
death occurred on the third postoperative day. As hemorrhage was 
not profuse, peritonitis or septicemia may have been the real cause of 
death. The second patient, aged hfty, Iiad a complete hysterectomy 
for cancer of the left ovary. She went into shock on the operating table 
never reacted completely, and died on the fifth postoperative day! 
Hemorrhage, during the operative procedure was, no doubt, the im- 
portant or contributory factor in the production of this so-called surgical 


Intestinal obstruction was the cause of the death of one patient This 

patient, aged thirty-five, had a subtotal hysterectomy trmulUple 



400 


AJIERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


lip omala ; eleven days after operation, a diagnosis of intestinal obstruc- 
tion was made. Ileostomy was performed, but the patient died twenty- 
four daj'S later. A loop of ileum adherent to the stump of the cervix 
was the cause of the obstruction. 

One patient succumbed from peritonitis. This patient, aged thirty- 
two, had a subtotal hysterectomy for multiple myomata. She exhibited 
the usual picture of general peritonitis and death oeeurred on the tenth 
postoperative daj*. 

Acute nephritis "with uremia was the cause of death of one patient. 
Ihis patient had a Porro cesarean section performed for sterilization 
purposes (having had three previous cesareans for a marked generally 
contracted pelvis). Forty-eight hours after operation, urine presented 
the typical findings of acute nephritis; anuria soon followed, then 
uremia, and death occurred on the fourth postoperative day. 

The cause of death of one patient is recorded as myocardial failure. 
This patient, aged sixty-eight, had had radium for cancer of fundus 
without cliecking the uterine homoridiage. A subtotal hysterectomy 
was performed and the course was a gradual one to exitus which occur- 
red on the twenty-second postoperative day. This patient was maz-kedly 
asthenic, and during the postopei*ative course developed a psychosis 
wliieh persisted to the end. Although this death is recorded as being 
due to myocardial failure, the general asthenia and debility of the pa- 
tient certainlj’’ played an important role in the result, as this patient was 
of the type on whom an operation should not have been done. 

Fibromyomata. (164 cases — 54.12 per cent.) 

The age incidence of myomata in this stud}' is in accord with the 
findings of most clinics. In over 90 per cent of this group, myomata 
were found betw^een the fourth and sixth decade. From 20 to 30 years, 
there were found eleven cases (6.6 per cent) ; from 30 to 40 years, 
sixty-six cases (40.3 per cent) ; and from 40 to 50 j^'cars, eighty-two 
cases (50 per cent). Only five (3.2 per cent) myomata were observed in 


patients over fifty years of age. 

The chief complaints of patients in this group, included the usual 
triad of abnormal uterine bleeding, abdominal pain and tumor of the 


abdomen. These were present in 90 per cent of the patients. Ninety- 
four patients (58 per cent) gave a history of abnormal bleeding; of 
which metrorrhagia occurred as the important symptom in 31.7 per cent 
and as an associated finding in six patients (8.6 per cent). Menorrhagia 
occurred as the chief complaint in 9.1 per cent and as an associated 
finding in twenty-one patients (12.8 per cent). Although abdominal 
pain was the important complaint in 35.9 per cent of the patients, i 
was present with varying degrees of intensity in /8 per cent o 
patients. Leucorrhea occurred in 28 per cent of the eases. 

Cardiac complications constituted the most predominant associated 
orgame derangement tonnd in this group of patients. Sixteen patients 



401 


SAMTJELS-EDLAVITOH : ABDOMINAIj HYSTERECTOMIES 


(10 per cent) showed some type of cardiac disease ; five with mitral in- 
sufficiency; three with mitral stenosis and in eight, cardiac hyper- 
trophy and dilatation was quite marked. This finding suggests that 
there may he some association of cardiac disease and uterine myomata. 
Hypertension in seven patients; diabetes mellitus in four patients; and 
syphilis in two ivere the only other important constitutional complica- 
tions of this group. 

The preoperative diagnosis of myoma did not cause much difficulty. 
An error of diagnosis occurred in fifteen cases (9.1 per cent) ; ovarian 
cyst in seven cases and salpingitis in four being the chief sources of 
error. 

Subtotal hysterectomy was performed in 155 cases (94.6 per cent) 
and a total hysterectomy in nine (5.5 per cent). Both ovaries were re- 
moved in thirty-three eases (20.1 per cent) . Conservation of the ovaries 
is practiced routinely by the attending surgeons of the Sinai Hospital, 
and though a 20 per cent extirpation may appear to be too high a per- 
centage for conservatism, further study of this group reveals that 21 
patients were over forty -two years of age. Only 7.5 per cent of these 
patients ivere young individuals and in most of these patients, the 
ovaries were removed because of ovarian pathology. Ovarian trans- 
plantation was not performed on any castrated patient. 

Postoperatively, the following complications were found to have de- 
layed convalescence ; pyelitis in four cases ; phlebitis in' six, and pul- 
monary embolism in three. Pulmonary embolism was attended with 
a high mortality, two of the patients succumbing. Although pulmonary 
embolism was diagnosed in only three eases, it is probable that it oc- 
curred with greater frequency, but as there were no alarming symp- 
toms, the condition passed unrecognized. Suppuration of the wound 
occurred in fifteen cases (9.1 per cent) and of the nine total hyster- 
ectomies performed in this series, three patients developed infection of 
the wound. 


The growths varied in size from 1 cm. to 25 cm. in diameter and were 
multiple in all but eleven. These eleven uteri presented submucous 
•growth which so distorted the size and shape of the uterus, that hyster- 
ectomy was the only possible procedure. Degenerative changes were 
present in 42 per cent of the myomata of which hyalinization and cal- 
cification were the most frequently noted. Liquefaction was present 
m two myomata; red degeneration in three, and five showed marked 
infection. Although sections are taken routinely, from the different 
growths, and also from any suspicious looking area, no evidence of 
malignant degeneration was found in any of the myomata. 

fiftv hyperplasia of the endometrium was observed in 

fiftj cases (30 5 per cent) ; forty-two of these patients (84 per centl 

? T , "to™ Mee«nr Cal 

.Ctoi hjqierplasia played in the production of this bleeding can only 



402 


ajikrican jouhnal of obstktrics and gynecology 

be con.iecUirocl, but in grou-lbs olher than submucous or endometrial 
polyp, its importance cannot be overlooked. 

Adenomyoma of the uterine Avail Avas noted in sections from fifty-eight 
uteri (35.3 per cent). In this pathologic classification Avere placed "all 
sections shoAving iiiA’asion of the myometrium by uterine glands and 
stioma. Sections irom most of these uteri shoAvcd a tj^pical microscopic 
picture of adenomyoma, but included in this grouping there Avere some 
atA pical sections, Avhich showed only t.Avo or three glands scattered in the 
superficial laj'cr of the myometrium, unassociated Avith endometrial 
stroma. These avc recognize as potential adenomyomas and Avere classi- 
fied under the diagnosis of adenomyoma. Thirty-eight (65.5 per cent) 
of these patients had abnormal uterine bleeding (the role adenomyoma 
played in the causation of the bleeding cannot be explained). 

Decidual tissue Avas observed in eight uteri (4.9 per cent). In these 
cases, pregnancy Avas cntirel.A’ unsuspected preoperatively by the op- 
erating surgeon and no doubt, had this condition been recognized, 
operative Avorlc Avould have been postponed. 

Sections from seven uteri (4.3 per cent) shoAved chronic metritis. 
In these cases, there Avas an associated chronic pelvic inflammation, 
Avhich is evidence of the inadequacy of conseiwatiou of the uterus in 
inflammatory disease of the adnexae. 

ADENOJIYOMA 

True adenomyoma Avas obsci-A’cd in tAvelve patients (3.96 per cent) 
of this series. All of these patients Avere married and multiparous Avith 
one exception. Adenomyoma Avas present seven times in the fifth 
decade, and four times in the fourtli decade. The diagnosis of adeno- 
m.yoma cannot be made preopei’atiA'^elj'’ Avith an}' degree of certainty. 
The most frequent error in the diagnosis is Avith mj^oma. In this anal- 
ysis, fibromyoma Avas the clinical diagnosis in six cases (50 per cent) 
and in the other cases, the preoperatiA^e diagnosis AA’as distributed OA^er 
six different pathologic conditions. Abnormal uterine bleeding aars 
the chief complaint of nine patients (75 per cent) ; metrorrhagia being 
present in eight and menorrhagia in one patient. Abdominal pain AA'as 
the chief complaint of tAVO patients, and Avas present in four othei 
patients. 

Subtotal hysterectomy Avas done elcA’^en times and total hysterectomy 
once. Bilateral oophorectomy Avas done on tAvo patients (16.6 per cent) 
as both of these Avomen Avere over forty jmars of age. 

Pathologically, eight uteri shoAved grossly the typical picture of 
adenomyoma. The uteri AA'ere enlarged to the left and posterior^, and 
Amried in size from eight to tAvelve centimeters. Jilinute hemorrhagic 
areas Avere seen scattered irregularly throughout tJie groAvths. The 
margins of the tumor and the uterine wall could not be discenied e- 
cause of the diffuseness of the groAvth. The opposite uterine wa 



SAM'OELS-EDLA.VITCH ; ABDOMINAL HYSTERECTOMIES 


403 


shoived marked tliickening measuring as miicli as 5 cm. in diameter at 
the midfundal level. The blood vessels in the uterine wall were very 
prominent and there were numerous areas of connective tissue inter- 
lacing the musculature. Microscopically, the growths showed many areas 
of endometrial glands and stroma, many of the glands were hyperplastic 
and filled with blood. Infection of the wall was observed in only one 

case. 


CHRONIC PELVIC INFLAMMATION 


111 this classification were placed all cases of salpingitis of pyogenic 
and gonorrheal origin. There were 77 eases (25.41 per cent) in this 
analysis. Whereas newgrowths of the pelvic organs are the most fre- 
quent pathologic conditions in elderly women, the antithesis in the 
young is salpingitis. 

Three patients were in their teens; 43 (60 per cent) were in their 
twenties; 25 (32.4 per cent) in the thirties and only 6 (7.8 per cent) 
were over forty years of age. Abdominal pain was the chief complaint 
of 65 patients (84.4 per cent). Of these, 20 (26 per cent) gave a history 
of abnormal uterine bleeding, menorrhagia occurring in 15, and metror- 
rhagia in 5 patients. As the chief complaint, abnormal uterine bleeding 
was present in 10 (13 per cent). Severe arthritis ivas the predominant 
complaint of 2 patients. It is interesting to note that 39 per cent of the 
patients in this group presented abnormal uterine bleeding — a finding 
which is in accord with the accepted belief of the occurrence of menor- 
rhagia and metrorrhagia in chronic pelvic inflammation. Leucorrhea 
was a constant symptom in every case, and stained smears were positive 
for the gonococcus in 8 cases (10.3 per cent). Syphilis Avas diagnosed 
serologically in 9 (11.7 per cent) of the patients. This is a significant 
finding, for the occurrence of sypliilis in the average run of patients 
of this hospital is less than 4 per cent. 

The clinical diagnosis in this group offered no difficulty, 'in 73 cases 
(94.8 per cent) the preoperative diagnosis was confirmed by operation 
and by pathologic examination. In 4 cases, chronic appendicitis and 
cystic ovaries ivere the incorrect diagnosis made on Uvo occasions. 
Although 9 patients Avere admitted to the liospital Avith a tentative diag- 
nosis of acute appendicitis, expectant treatment determined the true 
nature of the disease Avithin a short period of time. 


Subtotal hysterectomy Avas performed on 75 patients (97.5 per cent) 
and total hysterectomy on 2. Both ovaries Avere excised in 53 cases 
(68 8 per cent) and 21 (27.2 per cent) had a unilateral oophorectomy 
performed. Of these 21 patients, 14 gave a history of having had both 
tubes and an ovary removed at a previous laparotomy for chronic 
imlvic inflammation. The lapse of time from the first operation varied 
Irom eigh months to nine years; the ovarian tissue Avas conserved at 
that time because of the youth of the patient. Hence, the total number 



i04 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 

of patients in this grotip in whom castration was performed at the time 
of operation was 6/ (87 per cent). Although this figure may appear 
unusually high and may denote radical ovarian surgery, the following 
explanations must be taken into consideration : 

1. Ihat in over 60 per cent of these cases, chronic inflammation had 
produced such iri’cparable damage that conservative measures were out 
of the question. 

2. That many of these patients were wage earners and to suffer 
another economic loss from a possible second operation for the removal 
of a degenerated ovary excluded ovarian conservation. 

Postoperative eomplications. Bronchopneumonia occurred in three 
patients ; ether was the anesthetic used. Pelvic abscess developed in 
two patients and a posterior colpotomy was necessary. Pyelitis was 
a complication in two cases and phlebitis in two cases. Suppui’ation 
of the wound occui’red 17 times (23.2 per cent). This can be explained 
on the basis of direct contamination from the escape of pus in the re- 
moval of tlie tube or ovaiy during operative manipulation. These eases 
■were drained vaginally. Abdominal drainage wms done once in this 
series. 

Grossly, fibromyomata were found in 9 uteri. These were small sub- 
serous or intramural growths. Tavo tubes were microscopically the seat 
of an extrauterine pregnancy. Pyosalpinx, unilateral or bilateral, was 
observed in 12 specimens. Tuboovarian abscess was noted 8 times and 
h 3 ’'drosalpinx 11 times. Microscopical!}’’, infection of the uterus Avas 
a constant finding. Sixty uteri (78 per cent) showed definite infection 
of the endometrium. This infection varied in intensity in different 
uteri, some shoAved only a modex'ate increase in round cell infiltration; 
AA’hilc in others, there Averc seen in the endometrium extensiAm areas of 
round cell infiltration, changes in the stromal cells and destruction of 
the glands. Infection of the endometrium Avas found associated with 
infection of the AA’all in almost eveiy uterus. Chronic metritis was ob- 
served in 57 uteri (74 per cent). These findings certainly tend to cor- 
roborate the opinion of some gynecologists, Avho claim that radical 
uterine surgery is a necessity for an absolute cure of chronic pelvic 
inflammation. 

TUBERCULOUS SALPINGITIS 

One case of tuberculous salpingitis (0.3 per cent of the total series) 
Avas noted in this revieAV. The finding of 1.2 per cent corresponds Aiith 
the general incidence of tuberculous salpingitis. Greenberg in his anal- 
ysis at Johns Hopkins University found tuberculous salpingitis oecui 
red in 1 per cent of all cases of salpingitis. In this ease, there Avere found 
at operation and from section, the typical lesions of tubeieulous in 
volvement of the tubes. 



SAMUELS-EDLAVITCH : ABDOMINAE HTSTERECTOMIES 


405 


METRITIS 

Four eases (1.3 per cent of the total series) showed a marked degree 
of infection of the uterus. Two patients who were in the third decade 
of life had had a previous conservative operation for chronic pelvic in- 
flammation. One of these patients, aged twenty-nine, had been operated 
upon three years previously, at which time both tubes and one ovary 
had been removed. Abdominal pain occurred nine months later and a 
second operation was necessary. The other patient, aged twenty-seven, 
had been operated upon one year before, at which time a bilateral sal- 
pingectomy was done. Eight weeks before the second operation, the 
patient developed a gonorrheal arthritis and a laparotomy was per- 
formed removing the uterus and ovaries, the foci of infection. The 
remaining two patients, both in the fifth decade of life, had a subtotal 
hysterectomy performed because of severe metrorrhagia. No gross 
pathologic lesions could be demonstrated but microscopically, extensive 
infection of the endometrium and uterine wall was quite marked. 

MALIGNANCY OE THE HTERHS 

Sixteen uteri (5.28 per cent) in this analysis were the seat of malig- 
nant changes. The cervix was involved in 5 cases (1.65 per cent), the 
endometrium in 10 (3.3 per cent) and in one uterus, sarcoma was 
found in the uterine wall. 


CANCER OP THE CERVIX 

All 5 patients were between forty-one and forty-eight years of age, 
were married, and multiparae. Two patients had passed the menopause 
three and a half and two years, respectively. Vaginal bleeding appeared 
in one five mouths, and the other three iveeks before operation. All of 
the patients complained of metrorrhagia, the duration of which varied 
from one week in one patient to nine months in another. In 3 cases, the 
condition was recognized clinically and in 2 cases, the diagnosis was 
made in the pathologic laboratory. These 2 patients were hyster- 
ectomized because of multiple myomata and as suspicious ulceration of 
the cervix was noted, a total operation ivas performed. The sagacity of 
this procedure was substantiated by the finding of malignancy on routine 
histopathologic study. Panhysterectomy was performed on all the pa- 
tients under general anesthesia. Postoperative pneumonia delayed the 
convalescence of one patient and wound suppuration occurred in three 
eases. The frequent occurrence of infection of the wound in cases hav- 
ing a total hysterectomy performed has been a consistent finding in 
this study, and can only be explained on the basis of direct contanTina- 
tion from the vagina. There were no mortalities in this group during 
the hospital stay, but aU of the patients were dead within eighteen 
months following the operation. Of the five cases, three ivere considered 



m 


AMKUICAN JOURNAL OF OBSTETRICS AND GA'NECOUOGY 


iiiopcrubJo and t\vo clefinite].y operable. One of the three inoperable 
Ciiffcs had a tjiorougli cauterization of the cervix with tlie Percy cautery 
and several weeks later, the local involvement had so improved as to 
permit a panhysteroetomy to be done. Pathologiealbr, cauliflower 
{rrowtlus were pi'o.sent in three cases and two cervices exhibited an in- 
durated ulceration well localized and witliont invoh’ement of the para- 
metrium. Microscopically, all were squamous cell cancers, no cellular 
classification was made. 


ADENOCARCINOMA OP THE FUNDUS UTERI 

Ten uteri in this study were the .scat of malignant changes in the 
fundus. Those uteri were removed from patients all of whom were 
married and had given birth to one or more children; eight were 
Jewish and two non-Jewish. The ages were widely distributed from 
thirty-seven to sixty-eight years; 2 being in the late thirties; 3 in the 
late forties; 3 in the early fifties and 2 in the seventh decade of life. 
Nine of these patients presented mctiurrhagia as the chief complaint and 
one patient who showed no menstrual disturbance came to operation 
because of severe abdominal pain. Seven patients were past the meno- 
pause, for periods varying from four montlis to twenty years and it is 
interesting that 3 of tliese patients who were postclimateric four months 
to two years, complained of vaginal bleeding of onlj^ throe to six weeks’ 
duration, whereas 4 patients who Avere postclimateric ten to twenty 
years, complained of vaginal bleeding of four montlis’ to one j'ear’s 
duration. Tlie importance of educating women Avho have passed the 
climateric period of life to seek medical advice Avithont delay upon the 
reappearance of Amginal bleeding or spotting cannot be too strongly 
urgexl. 

Diagno.stic curettage Avas performed on 4 patients. Tavo AA^ere sub- 
jected to hysterectomy Avith the clinical diagnosis of adenocarcinoma, 
and in 3 eases, the malignancy Avas not suspected and Avas recognized 
in the pathologic laboratory. In one patient, because of ulceration of 
the cei-AUx, the preoperativc diagnosis of cancer of the cervix Avas made. 
Panhysterectomy was performed 7 times and the subtotal operation 3 
times. In tliese 3 patients, tlie clinical diagnosis was myoma, and as 
malignancy was not suspected, an incomplete opeiation was done. 
Grossly, these uteri shoAved unmistakable eAudence of eaneei o t le 
fundus. Examination of the opened uterus after excision at the opera - 
iiig table Ai’ouJd have revealed the true pathologic lesion, and tie com 
plete operation done. Incision of the uterus and examination o i 
endometrium at the table folloAAung a subtotal by stereetomj s ou c 
the routine of every surgeon. Only when this will be clone roii me j w 
unsuspected malignant changes of the fundus come to igi an 
complete operations he averted. Spinal anesthesia Avas use in 
complicated by diabetes mellitus, and avertin and ether m one 



SAMXJELS-EDLAVI-rCH: ABDOMINAL HYSTERECTOMIES 


407 


chronic myocarditis. Infection of the wound occurred m three cases 

in which total hysterectomy was done. 

Pathologically, four uteri contained intramural and subserous fibro- 
myomata. Grossly 9 uteri showed changes in the endometrium whici 
were easily recognizable as being malignant. In 5, the uterine cavity 
was a mass of necrotic, villous, decomposing tissue and in 4, the endo- 
metrium was hypertrophied, polypoid, friable, and spongy. In one 
uterus, there were no gross changes of cancer visible. This case, mmro- 
scopically, showed a very early adenocarcinoma of the endometrium; 
so early a. change as to suggest cure by curettage operation, several of 
such instances having been recently reported in literature. 


SARCOMA OP THE UTERUS 

In this analysis, one uterus was removed because of multiple myomata. 
These growths ivere subserous and intramural in variety and all "svere 
benign to gross and microscopic examination. Hoivever, in the left 
fundal wall unassociated with any fibromyomatous growth was observed 
an ulcerated growth of about 2 cm. in diameter which on histopathologic 
examination showed definite sarcomatous changes. This was apparently 
a true primary sarcoma arising primarily from the connective tissue of 
the myometrium. 

I 

MALIGNANCY OP THE OVARIES 


Malignancy of the ovaries wms noted 5 times (1.65 per cent) in this 
study. Tliree were primary adenocarcinomata and 2 "were papillary 
serous ej'^stadenomata with malignant changes. The three patients with 
cancer of the ovaries were married and multiparae. They had passed 
the menopause for a period of from one and a half to twelve years and 
were fifty, fiftj^-three and sixty-three years of age, respectively. Vaginal 
bleeding was the chief complaint and had been present from three days 
in one patient to seventeen months in another. Cancer of the ovaries 
was suspected in two eases and cancer of the fundus in the third patient. 
1 anhystereetom 3 ^ was performed on two patients and subtotal hyster- 
cctomj" wfith intestinal resection on the third. Wound suppuration oc- 
curred in both patients having a total hysterectomy. Postoperative 
pneumouia occurred in one case and vesicovaginal fistida was a compli- 
cation in another. 


Pathologieallj', these three cases presented the usual gross findings 
of cancer which was substantiated by microscopic study. 

Papillary serous cystadenoma Avith malignant changes, on the con- 
trarv was noted in young individuals. The patients were twenty-four 
and tlurty-five years of age; ivere married and had given birth to one 
01 more elnldren. One patient had had an exploratory operation six 
3 ears previous at winch time extensive metastases were found involving 
the omentum, intestines, and peritoneum. Only enough tissue for patho 



408 


AMKUICAX JOURNAL. OF OBSTETRICS AND GYNECOLOGY 


logic study Lvas removed at that time as the disease was considered in- 
operable. At a second operation, the growth was found well localized 
in the pelvis until no evidence of metastases to the abdominal viscera, 
riie uterus and ovaries were removed and histopathologic examination 
revealed that cancer was still present, but extensive calcification had 
taken place. This patient is alive and well eleven years after the first 
operation. The second patient was laparotomized for an abdominal 
tumor. Subtotal liystereetoni}'' with bilateral oophorectomy was done; 
patient’s recovery was delajmd by a postoperative pneumonia. Exami- 
nation of the ovarian cysts revealed grossly a papillary serous cyst- 
adenoma which on microscopic stiuty showed malignant changes. 

FIBROSIS OP THE UTERUS 

Nine uteri (2.98 per cent) in this series were classified as definite eases 
of fibrosis. Pathologically all these uteri presented gross eharactei'istic 
changes in the uterine wall. No other pathologic condition ivas observed. 
All the uteri were enlarged; the walls considerably thickened and 
measuring as much as 6 cm. across at the midfundal level. All showed 
numerous sclerotic vessels standing out distinctly in the walls and ex- 
tensive areas of connective tissue could be seen scattered throughout. 
Microscopically, the uterine walls showed marked areas of fibrosis and 
in many places, the myometrium had been entirely replaced by con- 
nective tissue. Advanced arteriosclerosis of the blood vessels was a ehai*- 
aeteristic finding. 

All these patients were married and multiparae, seven were between 
thirt3’’-five and fort3'-nine j^ars of age. Abnormal uterine bleeding was 
the chief complaint of six patients and menorrhagia Avas present in two 
other eases. In onl}’ tAvo cases AA’as the true condition susjiected. The 
preoperatiA'e diagnosis in three cases Avas myoma; in tAvo, oA'arian ej’^st; 
and in tAVO, abdominal adhesions. Subtotal hj’sterectomj’' Avas performed 
eight times and total once. Bilateral oophorectomj'' Avas performed on 
three patients because they Avere at the menopausal age. Pulmonaiy 
embolism AAdth recoA'’erj'' complicated the convalescence of one patient 
and Avound suppuration occurred in three other cases. 

HYPERPLASIA OP THE ENDOJIETKIUJI 

There Avere tAvo patients in this anal.ysis on Avhom a hysterectomy was 
performed for Amginal bleeding’. The onlj'^ pathologic finding Avas a 
hyperplasia of the endometrium. These patients Avere forty-tAvo and 
forty-six 3''ears of age, and both had had a diagnostic curettage per 
formed a short time previous to the laparotomy. Histopathologic exami- 
nation of the uterine scrapings revealed a typical Saviss cheese pattern 
of hyperplasia of the endometrium. Bleeding recurred soon after the 
curettage, and during a period of observation, the bleeding became moie 
profuse and a subtotal hysterectomy was performed. Pathologic 



409 


SAMTIELS-EDLAVITCH : ABDOMINAL. HTSTERBOTOMIES 

examination of these two- uteri showed a marked hypertrophy of the 
endometrinm, as the only abnormal findings, and on microseopic study, 
the same picture was noted as in examination of the scrapings Why 
these patients were not treated with deep x-ray could not be ascertaine . 

Normal; Eight uteri (2.6 per cent) exhibited no pathologic findings 
either in the uterus or the adnexa. Two patients in the group were 
single and four were under thirty-five years of age. Abnormal bleeding 
from the uterus was the chief complaint of three patients; abdominal 
pain of two patients, leucorrhea of one, nervousness of one, and pro- 
lapse of one. The preoperative diagnosis varied in these eases covering 
almost the entire field of gynecologic diseases. Subtotal hysterectomy 
was performed in all eight cases, and one patient near the menopausal 
age, had both ovaries excised. These cases should be dismissed with 
comment as being the result of the errors of human imperfection. 


PORRO CESAREAN SECTION 

Four Porro cesarean sections were observed in this study. All the 
patients were multiparae and between twenty-seven and forty-four years 
of age. The indications for the operation were as follows : 

Case I — (Generally contracted pelvis — ^three stillbirths due to 
difficult forceps operation and three cesarean sections. 

Case II — Pelvic deformitj^ — ^two previous cesarean sections. 

Case III — ^Multiple fibroids in a patient forty-four years of age. 

Case IV — Feeblemindedness. 

One-death occurred in this group giving a mortality of 25 per cent for 
this type of operative procedure. 

There was one case of accidental perforation of the uterus in this series. 
This patient had a curettage operation performed at her home. The 
uterus -was perforated and the omentum ivas found in the vagina. Im- 
mediate laparotomy revealed a uterus so irreparably damaged that a 
subtotal hysterectom 3 ’' was the only possible procedure. Histopathologic 
examination of the uterine -^vall and omentum showed marked evidence 
of infection. 


SUMMARY 


1. A series of 303 consecutive abdominal hysterectomies for a variety 
of pathologic conditions is reported with a mortality of 2.6 per cent. 

2. Approximately 85 per cent of the uteri were removed for myomata, 
chronic pehuc inflammation and malignancies, and the important symp- 
toms necessitating surgical aid were pain, bleeding, and tumor 

3. Cancer of the fundus of the uterus in this series occurs four times as 
often as cancer of the cervix. 

operations at periodic iiiter- 

Ir I r! “1 « to iPcrease the efficiency 

of file surgical departments of hospitals. ^ 



410 


AJIERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


REFERENCES 

Davis, J. E., anci Cvsiclc, P. L.: Am. J. Obst. & GYNEa 19: 246, 1930. Eorivitz 
A.; Surg., GjTiec. & Obst. 44: 355-358, 1927. Graves’ Te.xtbook of Gynecology’ 
Philadelphia, 1928, ed. 4. Burch, L. E., and J. C.; Am. J. Obst. & gVnec. 21:’ 
704-708, 1931. Grccnhcrg, J. P.: Bull. Johns Hopkins Hosp. 32: 52, 1921. 

1928 Eutaw Place. 


DO SPERM MORPHOLOGY AND BIOMETRICS REALLY OFFER 
A RELIABLE INDEX OF FERTILITY? 

G. L. SIoENCH, JI.D., New York, N. Y. 

TT IS not very inmsual to see a clinically sterile couple in whom the 
woman shows no discoverable anomaly and the husband has actively 
motile sperms. I have pointed out in previous papers^’ - that the pres- 
ence of actively motile sperms does not constitute proof of the man's 
fertility and that not a few appai-ently unsolved cases of disturbed fer- 
tility can be explained bj’ a complete morphologic and biometric 
examination of the spermatozoa, espeeiallj' of their heads. 

From the ]41 cases previously reported upon I drew the following 
tentative conclusions : 

1. A normallj" fertile man always ejaculates less than 20 per cent 
abnormal sperm heads. 

2. If the head abnormalities rise to between 20 and 25 per cent im- 
paired fertility is to be assumed and above 25 per cent there is always 
sterility. 

3. The graph constructed from 300 or more sperm head lengths in 
normal cases seldom shows a coefficient of variability above 11. 

4. 'With a coefficient of variability between 11.5 and 12.5 impaired 
fertility is present and above 12.5 sterilitAL 

5. A graph AAdiich shoAVS a skeAvness of 4 times the probable error or 
more alAva3’'S indicates disturbed fertilitj'- because such a graph can onh' 
be the result of either too manj’^ disproportionate]}' large, or dispropor- 
tionatel.A' small sperm heads. 

I noAv have 89 additional cases (making a total of 230) to report upon. 
Of these 89 cases, 5 represented normall.v fertile couples. The coef- 
ficients of Amriabilit}' of these 5 cases fitted A^erj’’ Avell into our preAuous 
noi-mal group (see Pig. 1). Of the remaining 84 couples, 63 had iieA^er 
had children; 8 had 1 or 2 children and AAmnted more; and 12 had had 
abortions but no liAung children. In one case a doubtful abortion oc- 
curred. The husbands in the case of the childless couples had no sper- 
matozoa at all in 9 cases (3 times after mumps around puberty with 
testicular atrophj', 5 times after gononhea and once unexplained). 
TAventy-seven men had more than 25 per cent abnormal sperm heads ; 4 
betAveen 20 and 25 per cent, and one, whose semen onty showed 18 per 
cent abnormal sperm heads, had 11.5 per cent narroAA'^ and tapering 



moench: fertility 


411 


sperm heads. Twenty-four men had normal seminal findings (13 to 18 
per cent abnormal sperm heads and a coefficient of variability between 
8.4 and 11.2) . The women in this group were 23 times at least not quite 
normal (closed tubes, hypoplasia uteri, cervicitis, endocrine dysfunction, 
etc.). Some of the disturbances were, however, not marked so that 7 
pregnancies occui’red in this group. One woman, still stei’ile, was ap- 
parently normal, so that the infertility is still unexplained here. All 
told there were 32 abnormal women among the 63 couples where the wife 



J*‘®toeram made up of the coefficients of variability of the normal cases 

who'lfm^raf^oto (it^easnred in half and 

became pregnant as swn as thfs waf man had a cervicitis and 

number of spenn Iieads of a particular size number^ show the 
sperm heads in mm. at 3000 diameter maCTificaUon. horizontal the size of the 


■ Pi'e^^ant. In 3 cases the woman had closed faUopian 

Lrx 

To show tlK iinportanee ot a caretiil examination of the semen I lave 



412 


A3IERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


except a marked cervicitis. The husband was thirty years old and physically normal. 
The semen contained many actively motile spermatozoa. Head abnormalities were 
only 13 per cent and the coefficient of variability was S.673±.240 (see Fig. 2). After 
the cervicitis was cleared up the wife promptly became pregnant. 

Case E. P., white woman, twentj’-six years old, married three years, never 
pregnant, no contraceptives used. The only physical abnormality was a marked 
cervicitis. The husband was physically normal, twenty-nine years old. The semen 
contained many actively motile spermatozoa, but there were 28 per cent abnormal 
head forms present and the coefficient of variability was 12.600 ±.352 (see Fig. 3). 
Although the cervicitis was cleared up, pregnancy did not occur and has not up to 
now, two years later. An artificial impregnation carried out by another gynecologist 
was also ineffective. 

In the 8 couples -who had had children but wanted more, the husband 
was over lift}' yeavs old in 4 instances and close to fifty in 2 others. Ap- 
parently a diminution of the fertility had set in in these eases purely on 



the basis of age. The head abnonnalities in these cases were always 
abundant, between 21 and 31 per cent. One woman of this group had 
closed tubes at the time of the examination apparently after an induced 
abortion and one had grown very stout and was an e'vddent case of endo- 
crine dj'^sfunction. 

In the 13 couples who had had no children but wdiere the wife had had 
one or more abortions, the woman had closed tubes 5 times after induced 
abortion and the husbands showed between 20 and 25 per cent abnormal 
sperm heads in 6 cases. In 2 cases no cause at all could be found for the 
spontaneous abortions which the Avoman had had. Thus among 84 
cases the man was apparently normal in 33 and the woman in 44. These 
figures are, however, not to be taken as generall.v applicable because our 
eases were not random samples but more or less picked. Thus verj often 
a man was sent to me only because the sterility in the particular case 
was not explained. I think it is worth while to emphasize that 7 out ot 



MOENCH: FEBTILITY 


413 


10 women, wliose husbands had between 20 and 25 per cent abnormal 
sperm heads, had had spontaneous abortions. 

The findings in these additional 89 cases thus seem to corroborate m 
every way the tentative conclusions which were drawn from the pre- 
viously investigated 141 cases so that I really believe, we may say that a 
morphologic and biometric examination of the semen offers a method for 
discovering disturbed male fertility. 

In interpreting the seminal findings one must, however, not forget that 
seminal morphology and biometrics do not necessarily run parallel for 
reasons already stated (Moench, 1. e.). Thus neither a normal mor- 
phology alone nor a normal biometric result alone means that the semen 
is normal. On the other hand a distui'banee in either one of these 2 fac- 
tors means disturbed spermatogenesis and thus impaired fertility. A 
marked ske^vness also indicates the same thing. 

It maj’’ seem improbable to some of my readers that such a relatively 
small percentage of abnormal heads can have any influence on fertility. 
1 believe, however, that the correct interpretation of my findings is that 
the number of abnormal sperm heads indicates the degree of the sperma- 
togenic disturbance and that the other sperm heads although they may 
appear normal to our rather crude microscope, are not normal when the 
disturbance of the spermatogenesis reaches certain high levels. 

Perhaps this explanation may still not satisfy some of the skeptics. 
They perhaps cannot believe that such minute details of seminal examina- 
tion can really constitute an indicator for male fertility. Here I can 
only answer that among all our cases there was not a single one in which 
the clinical outcome of the marriage contradicted the prognosis which we 
had made purely on the basis of the microscopic findings. Thus the 
wives of a number of men Avhom we declared normal, became pregnant 
later on, but not a single -woman, whose husband we found sterile accord- 
ing to the standards outlined here, became pregnant as long as the dis- 
turbance of die spermatogenesis persisted. There were also" many eases 
which had been considered unexplained before which almost explained 
themselves when the results of the semen examination Avere taken into 
consideration. 


REFERENCES 

■rr 3toe)ic7i and Holt: Am. J. Obst. & Gynec 22’ IQQ nr i „ 

Soli; J.Lab. &Cim.Mea. 17; 297,1932. ’ Moench and 

30 East 58th Street. 



VESICOURETERAL REFLUX AS AN ETIOLOGIC FACTOR IN 
PYELITIS OF PREGNANCY 

Harold L. aionius, M.D., P.A.C.S., and James F. Brunton, M.D., 

Detroit, Mich. 

TOURING the past twenty yeai's numerous investigations have been 
earned out in an attempt to definitely determine the true etiologj^ 
of pyelitis of pregnaney. At this time no definite factor or factors have 
been agreed upon, but the results of the various investigations have 
added considerablj^ to our knowledge of the frequenc}’’, pathologj% and 
treatment of this condition. 

Two modes of infection of the renal pelvis are described by nearly 
eveiy writer on this topic: (1) hematogenous, and (2) Umiphogenous. 
The question as to whether thei*c is an ascending infection by way of 
the lumen of the ureter and a resultant infection has been reopened re- 
cently by Barksdale.^ 

The views of manj" writers that this type of renal infection is sec- 
ondary is significant. The original focus of infection may be in the 
upper respiratory tract, teeth, tonsils, sinuses or gastrointestinal S 3 ’^stem, 
the organism gaining entrance to the kidnej's bj’- the circulatory or 
ljunphogenous routes. l\IeComb- mentions the ascending lymphogenous 
route in cases of pregnant women with cj'stoeele, residual urine, and 
bladder infection. 

Since the bacteriologic findings indicate that in the majority of cases 
Bacillus coli is the offending organism, the gastrointestinal sj’^stem is 
looked upon as the original cause of this condition. Constipation is 
common among these women, although manj’^ are loath to admit it. 
One dailj’' boAvel movement is not CAudence that constipation does not 
exist; the rectum maj’’ not be coinpletelj’’ emptied at each defecation. 
Franke and Stahr, as quoted bj’’ Shields,® haA’^e shoAvn that the Ijanpliatics 
of the large boAvel on the right side pass oA'^er the capsule of the right 
kidnej’’, and that the deep ljunpliatics of the kidnej'’ communicate v.ntb. 
those of the capsule, Avhich maj' substantiate the theoiy of direct in- 
vasion of the kidney from the large bowel bj'" Avaj'’ of these lymphatics. 

The question of uterine pressure upon the ureters at the pelvic brim seems to be 
totally discounted by the majority of recent contributors. They do not however, 
wair’e the factor of uterine compression in the pelvis. Carson^ reports 16 cases 
of pregnancy which came to autopsy, and in each case the enlarged uterus was seen 
to press directly upon the right ureter, and that from this point upward the ureter 
was definitely dilated. He contends that the sigmoid flexure of the colon seems to 
protect the left ureter to some extent. AA^ien the uterus was lifted out, the pelvic 
portion of the ureter was seen to fill. Apparently there are still some adherents to 
the view that mechanical pressure is an etiologie factor in pyelitis of pregnancj, 
quoting the dextrorotation of the pregnant uterus as an additional factor. 

414 



MOKRIS AND BBUNTON : VESICOURETERAL REFLUX 


415 


We are indebted to Duncan and Seng^ for a detailed and comprehensive study of 
the urinary tract during pregnancy. In their investigation of 78 cases, they have 
reported finding a general engorgement and congestion of the urethra, and bladder 
mucosa; and a congestion, lengthening of the diameters and elevation of the inter- 
ureterie ridge of the trigone, all these occurring as early as the eighth week. They 
could not demonstrate any changes in the ureteral orifices. 

Dilatation of the ureters has been investigated by a number of authors, notably 
Hofbauer,® Duncan and Seng, Baird,’ Crabtree,* and others. 

Very few writers mentioned the question of stasis due to renal dystopia. Pugh" 
cites this as a predisposing factor. Stevens and Henderson” mentioned the fact 
that four-fifths of the cases of renal dystopia occur in women. In our own in- 
vestigations” we know that renal dystopia occurs on the right side in 32 per cent 
of all investigated cases; that the majority of these cases, even while not pregnant, 
harbor infection in the renal pelvis; and that women are more prone to renal dystopia 
than men, irrespective of age and weight. We consider that stasis could easily be 
an important etiologic factor in pyelitis of pregnancy, and perhaps a very important 
one. 

The recent clinical and pathologic findings of a number of uTiters have turned 
the attention of those interested in this question to the changes in the ureteral ivall 
during pregnancy. Papin” reports Jolly’s findings of ureteral dilatation in 12 
to 15 per cent of cases of pregnancy. The right ureter being involved more often 
than the left, and if there is involvement of both, the right shows the greatest amount 
of dilatation. Duncan and Seng have confirmed these findings, and also state that 
it is demonstrable as early as the sixth week in multiparae, and the tenth week in 
primiparac. This condition reaches its maximum during the twentj'-fourth week 
in primiparae and the twenty-second week in multiparae. The right ureter showed 
some dilatation in every one of their 78 cases. Bilateral dilatation was more com- 
mon in multiparae. Tliey were also impressed rvith the fact that the ureter, like 
the perineum, involutes to a normal but relaxed state, and that there is some 
degree of dilatation long after the rest of the tissues had resumed normal. Ureteral 
distortions were found as early as the sixteenth week and more frequently in the 
antepartum cases, klarked hydroirephrosis was found more frequently in multip- 
arac. They consider stasis to be an important factor in the development of 
pyelitis. In their cases the left pelvis emptied itself in the normal limit of seven 
minutes. In the delayed cases the right side outnumbered the left in the propor- 
tion of four to three. Ureteral dilatation and hydronephrosis appear and reach 
their maximum early in pregnancy. Stasis however, does not appear until the 
twentieth week. They agree udth Carson that pressure at the pelvic brim is re- 
sponsible for the dilatation of the ureter, and that stasis was relieved after the 
delivery of the child. 

An increase in the amount of connective tissue and muscle fibers has been 
demonstrated by them; a moderate amount in the upper third; a less amount in 
he middle third; and a marked increase in the lower third. They believe that this 

regurgitation and only becomes patlio- 
logic ■wiicu the musculature becomes atonic. ^ 

Baird, reporting the results of his investigation of 1000 cases of weimnno. 
admitted to the Glasgow Royal Maternity and Women’s Hospital, found minary 

liters; :n;f- •• 

Hofbauer discounts the compression theory since manv nf vi- 



416 


AJIEUICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


gravity of the pregnant uterus is the same as that of the other abdominal organs 
(DeLee). He has described in great detail the pathologic findings in the ureters 
during pregnancy which consists of definite hj’perplasia and hj’pertrophic changes 
in tlie lower third and juxta vesical ureter where it passes through the parametrium, 
and has found that similar changes occur in the trigone. Such changes are less 
marked in the abdominal ureter. He also states that the mucosa of the ureter 
shows thickening due to edema. Tho changes noted in the ureters arc also found 
in the interureteric ridge of the trigone. The striated muscle of the vesical neck 
and proximal portion of the urethra are definiteh' increased. As a result of these 
changes there is a tendency for the lower portion of the ureter and trigone to be- 
come a dense unyielding structure, and a definite has fond is formed beyond the 
trigone resulting in residual urine and stasis. Pemberton in discussing Hofbauer’s 
paper considers that if this explanation is the fundamental one then pyelitis should 
be more frequently bilateral. 

We have considei’od it iieeessaiy to I’evieiv the current literature on 
tile etiology of pyelitis of pregnancy before presenting our own findings, 
in order that a complete understanding of the whole phase of the sub- 
ject might he more clear. 

The problem we outlined for ourselves was to determine as far as 
possible Avhethcr the theory of ascending infection to the renal pelvis by 
way of the lumen of the ureter was tenable, and if so to what extent it 
is a factor in pyelitis of pregnancy. Our investigation was prompted 
by a recent article by Baiitsdale, in which he demonstrated the phe- 
nomenon of reflux in 83 per cent of pregnant dogs. This means of 
ascending infection has been considered for some time since Young^® 
in 1898 attempted to demonstrate reflux, but without success. Eisen- 
drath^'^ reported that reflux did not occur in his series of 41 eases of 
pregnancy. Bumpus,'® at the Majm Clinic, demonstrated 89 cases of 
reflux in a series of 1036 cystograms, and concluded that reflux was 
never found in the normal bladder except in children. Kretschmer^® 
reports the finding of reflux in childi'cn under anesthesia. 

There is a difference of opinion as to the causation of reflux. That 
it may be due to a congenital inability of the lower end of the ureter 
to oppose the reflux when the bladder contracts is admitted, but this 
would be applicable in only a veiy few cases. 

There are other groups of cases where reflux has been demonstrated: 
(1) severe acute cystitis, (2) chronic nontuberculous infections of the 
entire urinary ti'aet, (3) genitourinaiy tuberculosis, (4) mechanical ob- 
struction at the bladder outlet, (5) cases of neurologic origin (spinal 
injuries, myelitis, spinal syphilis), and (6) pernicious anemia. 

Papin lias been able to demonstrate reflux by a slow filling of the bladder m ap- 
parently normal individuals, which might support the theory that reflux can occur 
by a hypertonic contraction of the bladder wall on its contents, and thus permit 
the opening of the ureteral orifices and reflux to occur. If an acute or chrome in- 
flammatory change in the vesical or ureteral wall interferes with proper closure o 
the ureteral orifices, ascent of the bladder content can be expected, but one could 
hardly term this a reflux; more properly regurgitation, since it implies a gaping 



MOKRIS AND BRUNTON: VESICOURETERAL. REFLUX 


417 


ureteral opening and lack of complete physiologic function of the intraparietal 

“'tatani” follorving animal experimentation has stated that there is normally no 
reilu^rto the uretl, and that prevention of redux is referable to a physrcal and 
physiologic activity: (1) the distended muscle fibers over the ureter tend 
L ureter together, (2) a layer of longitudinal muscle as found on the outer side 
of the intraparietal part of the ureter, and (3) Waldeyer’s sheath covers the medial 
side of the small section ,iust above the intraparietal part. The contraction of the 
outer fibers tends to close the orifice, and contraction of Waldeyer's sheath 
causes the lip-shaped upper rim to protrude. 


During tlie past five montfis ■we have cond'acted a clinical investigation 
in 104 cases of pregnancy in the third trimester, -with a vieiv to ascertain- 
ing the frequency and significance of vesicoureteral reflux. Cases in the 
third trimester only "were selected ; as ■we considered that the maximum 
effects of uterine pressure ■would be apparent in that period, if uterine 
pressure could be a factor in the etiology of pyelitis during pregnancy. 

Catheterized specimens ■vi’ere taken in every case, for the purpose 
of obtaining routine chemical urinalysis, cell counts, and cultures. 
Every care u'as taken to observe a strict aseptic technic. The bladder 
was slowly filled and 30 e.c. of 15 per cent sodium iodide added. No 
attempt was made to distend the bladder to the point of discomfort, as 
we did not wish to set up bladder spasm by distention. Each patient 
was placed in exaggerated Trendelenberg position for ten minutes, 
and at the end of that time eystograms were taken on a 14 by 17 film. 

In the whole series of 104 cases the phenomenon of ureteral reflux 
could onls’" be demonstrated in two : 


Case 1. — There were no symptoms referable to the genitourinary system. Uri- 
nalysis, culture and cell counts did not reveal any evidence of infection. The re- 
flux was bilateral and confined to the lower third of the ureters. It was noted at 
the time that this patient had voided some of the contents of the bladder during 
the ten-minute period and before the cystogram was taken. This case may be either 
a congenital one, or as mentioned previously, as having a hypertonic contraction 
with reflux. Cystoscopy after term showed bilateral elevated and gaping ureters, 
but no evidence of infection was obtained, Bepeated attempts have been made to 
have this patient return for further cheek up by means of pyelograms, but ivithout 
success. She was a para i, aged twenty-nine. 


Case 2.--This woman had no genitourinary tract complaints beyond that of back- 
ache, and slight frequency of urination which she attributed to the pressure of the 
uterus. She was returned to the urologic department after demonstration of right 
nreteral reflux, and a large amount of pus in the urine. Treatment was instituted 
.and an attempt was made to demonstrate any abnormality of the genitourinary 
tract by means of intravenous skiodan but without success. Improvement was 
noted antepartum following cystoscopy and drainage by means of nreteral catheter- 
wation There was an obstruction to the right catheter about 2 to 3 cm. from the 
ure era opening. Twelve days postpartum she was cystoscoped and turbid urines 

. , ‘ ■ Cystogram showed a pronounced irregularity in the reeion of Hip 

ri^t ureteral opening resembling a diverticulum. PyelourJterog^ams were mat 



418 


AiMEIUCAN JOUUXAL OP OBSTETUICS AND GYNECOLOGY 

ureter, tortuous throughout its extent. There .vas some dilatation of the left pelvis 
and ureter. The bladder had a large c.apaeity. A bilaterhl renal ptosis was also 
noted. Another set of pyeloureterograms were taken, six weeks following delivery 
and the conditions noted before were still present, but dilatation of the right ureter 
was not so pronounced. 

J\rultiparae made up the largest group in this series with a total of 62 
and the parity of this group was arranged as follows : 


Pnra ii 

28 

ill 

15 

iv 

10 

V 

1 

vi 

3 

vii 

2 

\iii 

2 

xi 

1 


62 

The remaining 42 were, of course, primiparae. 

The type of infection encountered was staphylococcus and Bacillus 
coli. Forly-one eases grew organisms on culture and in none of these 
were tliere any symptoms of genitourinary tract disturbance. Staphylo- 
coccus occurred in 34 and Bacillus coli in 7 cases. There was a total of 
60 with evidence of focal infection, chiefly in the teeth ; of that number 
23 showed evidence of urinary tract infection, the remaining 37 did 
not. Evidence of infection was obtained on culture in 18 cases who 
were without focal infections on examination. 

Other -writers have found Bacillus coli to be the preponderant or- 
ganism in urinary tract infection during pregnancy. It might be sug- 
gested that the large incidence of staphylococcus infection in our series 
could be due to the focal infections. We know that asymptomatic bae- 
teriuria does occur in pregnancy, but one Avould hardty expect it in so 
large a number of eases. 

Seven eases at subsequent examinations were diagnosed as definite 
higher urinary tract infection. In none of these could reflux be demon- 
strated. The distribution of tliese infections is as follows : 

Bilateral Pyelitis 3 Right Pyohydroneplirosis 

Left Pyelitis 2 -with Right Hydroureter and 

Right Pyelitis 1 Bilateral Ptosis 1 

Prom a consideration of our findings in this series, it would seem that 
if the pathology previously noted by Hofbauer is correct, and the lower 
portion of the ureters and trigone are involved in a structural change 
forming an “unyielding rigid tube,” then reflux should be demonstrable 
in a larger number of eases, particularly in the mitltiparae who have 
had a number of pregnancies. We cannot conceive of the changes he 
describes taking place a number of times without causing an atomcity 



MORRIS AND BRUNTON: VESICOURETERAL REFLUX 


419 


of the lower end of the ureter and trigone. We are inclined to the be- 
lief that this structural change is a protective mechanism to preserve 

tone and function in these structures. 

It would also seem apparent that only in an isolated case can reflux be 
demonstrated in an individual without signs of urinary tract infection. 
The presence of a higher urinary tract infeetion with involvement ot 
tlie ureters and bladder is not sufficient to give rise to reflux unless 
accompanied by an atonicity of these structures ; in that event, the in- 
fection and involvement of the genitourinary tract would be quite ex- 
tensive as noted in our second case. Reflux could not be demonstrated 
in our seven eases of higher urinary tract infection, although one of 
these had progressed to the stage of a pyohydronephrosis with hydro- 


ureter. 

The presence of cystocele during pregnancy is not an obstructive 
lesion in so far as reflux is concerned. In this series there were thirteen 
with cystocele, and reflux was not demonstrable. 

We are of the opinion that the question of stasis should be given more 
consideration as an etiologie factor in pyelitis of pregnancy. In the two 
severe cases of infection in this series renal ptosis was demonstrated. 

In no patient was there the slightest evidence of interference or inter- 
ruption of the pregnancy as a result of the cystograras made in the 
Trendelenberg position. 


REFERENCES 

(1) Barhsdale, E. E.: Am. .T. Urol. July, 1931. (2) McComh, B. J. A.: J. 

Canad. M. A. 296, Sept., 1931. (3) Shields, F. E.: Am. J. Surg. 6: 774, 1929. (4) 
Corson, IF. J.: Am. J. Urol. 16: 167, 1926. (6) Duncan and Seng: Trans. Am. 

Gynce. Soc. 53; 67, 1928. (6) Eofbauer: New Eng. J. M. 198: No. 9, 1928. (7) 

Baird, D.: J. Obst. & Gynec. Brit. Emp. 38: 516, 1931. (8) Crabtree, E. G.: Trans. 
Am. Assn. G. U. Surg. 22: 149, 1929. (9) Pngh, W. S.; M. J. & Eec. p. 127, 1928. 
(10) Stevens and Henderson: J, A. M. A. 93: 1282, 1932. (11) Morris, Sherman, 

and Brunton: Renal Dystopia. Am. J. Surg. September, 1932. (12) Papin - Les 

Hydronephroses, 1930, Dion et Gie. (13) Young, E. E.: Bull. Johns Hopkins Hosp. 
9: 105, 1898. (14) Eisendratli: Proc. Urol. Sect. A. M. A., 1925. (15) Bumpus: 

Am. J. Urol. 12: 341, 1924. (16) Kretschmer, E. L.: Surg. Gynec. Obst. 21; 228, 
191o. (17) Satani, T.: Am. J. Physiol. 49; 474, 1919. (18) VanDusen, and 

P- h 1928. (19) Pride, TF. T.: Urol. & Cut. Rev. 31: 
440, 192(. (20) Mdler: N, Y. State M. J. 28; 720, 1928. (21) Kahn J W ■ 

I®-' Danforth: Gynec. irons. 

52. 141, 19../. ic3) Sexton, W.G.: Wise. M. J. 28; 104, 1929. (24) FrnhinshoE, 
P- IP-P- (25) A'-ewel, P. S.: New Eng. J. M. 82- 371 

m30. (26) Prather and Crabtree: New Eng. J. M. 202: 366, 1929 (27) Massev 

;4r o 1929. (28) lose and Hollins J . KlCT 9^1^] 

n r State M. J. 26: 408, 1930. (30) Bngbee 

H. G.. Bull. Lymg-In Hosp. City of N. Y. 12; 11, 1920. (31) Davis B ■ Bull’ 

of N. y. 12: 30, 1920. (32) Miller, E. A.: Pa M J 2l ’ 

Obst. 22; 783, 1916. (34) Blaci 

So. 12; 39,1919. (35) yVool,G,K,: Wise. M J 28- 107 1090 r^r\ 
Crabtree and Prather: New Eng. J. M 202- 357 lOifi caVt irn" • * a t ' (^^) 

Ajt. .1. Oust. & Gyxec. 22; 211, 1931. ’ Langlois: 

411 PROrESSIO.N-AL BtJlLDlXG. 



AN ACCOUNT OF A YEAR’S SERVICE IN OBSTETRICS AT THE 
MORRISANIA HOSPITAL: A PUBLIC INSTITUTION^^ 

Harry Aranow, jM.D., New York City, N. Y. 

(Director of Obstetrics) 

T REALIZE fully that a short scries of one thousand cases cauuot be of 
great interest to a society of specialists, yet I believe such a report will 
add some jiroof to the theory that the most important causes of the prevail- 
ing liigh mortality rate are unnecessary interference and lack of proper 
training of the obstetric attendant. 

Starting Avitli a partlj' finished, partly equipped, new municipal hos- 
pital, a new staff of men who never worked together, a new staff of nurses, 
without any established technic, refusing no admissions and accepting all 
the desperate eases that are brought in b.y the public ambulance, we suc- 
ceeded in making a fairly creditable record. This we did by eliminating 
unnecessarj' interference and so supeiwising the work of the staff, that, 
while enjojdng full freedom of action, the men were guarded against go- 
ing beyond their depth. 

The Morrisania Hospital, a municipal institution, was opened on July 
1, 1929. During the first year we had a total of 976 deliveries. Of these, 
375 or 38 per cent of the mothers were primiparae and 601 or 62 per cent 
wore multiparae, 739 or 75 per cent w'ere wliite and 237 or 25 per cent were 
colored, 881 delivered normally and only 95 were delivered by operation, 
an operative incidence of 9.7 per cent. 


Table I. Opekatjve Delivekies 


operation 

NUJIBBR 

FREQUENCY 

jiaternal deaths 

FETAL DEATH 

NEO. 

STILLBIRTH 

Low forceps 

1 

57 

i 

5.9 

0 

1 

o 

Mid forceps 

IS 

l.S 

0 

' 0 


High forceps 

0 

0 

0 

u 


Version 

14 

1,4 

2 



Cesarean section 

6 

0.6 

0 

1 


Total 

95 

9.7 

2 

5 

9 


Forceps applications were strictly limited to definite indications in the 
interest of mother or child. The three fetal deaths in low forceps deliveries 
include, one macerated stillbirth, one “bab 3 '’ dead on admission, ^ and one 
neonatal death caused bj^ a congenital anomaIJ^ The one stillbirth in a 
midforeeps deliveiy was caused by a prolonged labor. There were no ma 
ternal deaths. 

by invitation at a meeting of the New York Obstetrical Society. May 11. 1932. 

420 


ARAKOW: tear’s SERVICE IN OBSTETRICS 


421 


Most of tlie versions were done for serious indications. As a result of 
the underlying complications, the maternal and fetal mortality was neces- 
sarily high. The indications included, prolapsed cord 2 eases, transverse 
position 2 eases, placenta previa 4 cases, toxemia 2 eases, delay in dehvery 
of the second twin 3 cases, and elective 1 case. The causes of death m the 
mothers were hronehopneumonia 1 and eclampsia 1. There were 6 still- 
births as follows : a premature, one of twins (no apparent cause found) , a 
prolapsed cord with no pulsation on admission, nephritis of mother and 
prematurity, placenta previa of mother and eclampsia of mother. There 
were 3 neonatal deaths, one baby with congenital atelectasis and two in 
mothers with placenta previa. 

Cesarean section was resorted to 6 times, an incidence of 0.6 per cent. 
The indications were as follows : previous cesarean 2 eases, and contracted 
pelvis 4 cases. The low flap operation was done twice and the classical 4 
times. There was no maternal mortality and one neonatal death w’^as 
caused by a gastrointestinal anomaly. 

There were 330 lacerations of the perineum, an incidence of 33 per cent, 
186 were in primiparae and 146 in multiparae. Of the lacerations 247 or 
75 per cent were first degree, 80 or 24 per cent second degree, and 3 or 
0.9 per cent third degree. Unilateral episiotomy was performed 39 times, 
an incidence of 1.2 per cent, showing a strongly conservative tendency. 

We had a total of 944 vertex, 29 breech and 3 transverse presentations. 

Persistent oecipitoposterior position requiring interference occurred 9 
times, an incidence of 0.9 per cent. The Pomeroy maneuver followed by 
forceps was used 4 times, the Seanzoni 4 times, and manual rotation of the 
head followed by forceps once. We were fortunate in getting perfect re- 
sults. The low incidence of interference in a successful series is a strong 
argument in favor of a “watchful waiting” policy in the treatment of 
posterior positions. 

Face presentation occurred 3 times, 2 mentoanterior and one mento- 


posterior which I’otated anteriorly. All delivered spontaneously. 

Breech presentation was encountered 29 times, an incidence of 2.9 per 
cent. Our treatment was strictly conservative. We had no maternal mor- 


tality and an apparently high fetal death rate, 8 stillbirths and 2 neonatal. 
However, 7 of the 8 stillbirths were early, nonviable prematures, and one 
of the neonatal deaths was caused by a congenital primary anemia. This 
gives a corrected mortality of 2 or 6.9 per cent. 

Transverse position occurred 3 times. One baby was dead on admission, 
one was stillborn, and one survived. All the mothers did well. 

We had 31 cases of hemorrhage complicating pregnancy and labor. 
Nineteen were caused by atony of uterus, 2 by retained placenta, 6 by pla- 
eenta previa, 3 by premature separation of placenta and 1 by rupture of 
ntcnis In 11 of the cases of atony of the uterus the hemorrhage was con- 
t oiled bj massage, pitiiitnii, and ergot and in 8 by uterine packino- Of 
ho letaiiied placentas one delivered spontaneously and one had to be re- 



422 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGA' 


moved manually. Five of the placenta previas were marginal and one 
central. They were all treated conservatively, one by rupturing the mem- 
branes, four by bagging followed by version, and one by forceps. 

Because of some veiy tragic experiences with the conservative treatment 
of placenta previa, I have come to the conclusion that cesarean section is 
the safest procedure in the majority of eases. IMy associates, however, feel 
that in a Avell established hospital, with everything set for an emergency, 
the conservative treatment is just as safe and, thus far, they have proved 
their contention. 

All the cases of premature separation of the placenta were mild. One 
delivered spontaneously and two Avere delivered by bagging and Aversion. 

The case of ruptured uterus A\'as brought in on the ambulance in shock 
and died from shock and hemorrhage AA'ithin an hour. This AA^as our only 
death from hemorrhage and shock. 

There Avere 21 eases of late toxemia of pregnancy; 6 preeclamptic, 6 
nephritic, and 9 eases of true eclampsia. 

Of the preeelamptics 4 Avere primiparae and 2 multiparae. They Avere 
all treated conservatively by rest in bed, eliminatives and, Avhen indicated, 
sedatives. One para iv Avith a history of a previous eclampsia Avas induced 
by bougie and packing. All the mothers and all the babies, including one 
premature, Avere saved. 

Our diagnoses of nephritic toxemia AA'ere checked by the recognized kid- 
ney function tests. Of the 6, 3 delivered normally, one AA^as induced and 
delivered normally, one Avas delh'ered by forceps, and one bj’' bagging and 
Aversion. All the mothers reeoA’-ered, but Ave lost 3 of the babies, one from 
the toxemia of the mother and 2 from prematurity. 

All of our eclampsia cases AA'ere emergency, i. e., they AA'ere brought in 
on the ambulance, not one of them coming from our prenatal clinic. To 
the credit of the men in charge of our prenatal clinic let me repeat the fact 
that not one of their eases deA-^eloped eclampsia. Of the 9 eclampsias 7 
Avere in primiparae and tAvo in multiparae : 5 developed convulsions ante- 
partum, 1 intrapartum, 1 postpartum, and 2 combined. Our eases AA'ere 
nearly all of the severe, neglected type. They Avere all started on the 
Stroganoff method until the couA'ulsions AA'ere controlled. If their general 
condition did not sIioaa' any marked improvement, labor aa'RS induced. We 
lost tAvo of the mothers, an uncorrected mortality of 22.2 per cent. Only 
tAA'o of the babies Avere full term and they AA'ere both saved. The other 7 
AA'ere premature ; 6 AA'ere stillborn, and one died shortly after birth. 

Fh'e cases of serious organic A'ah'ular heart disease Avere encountered. 
Four had double mitral lesions and one a mitral regurgitation. Two gave 
a history of previous decompensation and one AA'as decompensated at the 
time of admission. With rest in bed (our rule is to keep all serious cases 
of cardiac disease in bed for four Aveeks before delivery) , diet, medication, 
and careful management of their labor, all our patients delivered and AA'ere 



ARANOW; year’s SERVICE IN OBSTETRICS 


423 


discharged apparently none the worse for their experience. One baby 
died from congenital atelectasis. 

According to onr records we had only 9 cases of serious pelvic contrac- 
tion ; one general contraction, one funnel type, and 6 flat pelves. The one 
with general contraction delivered normally after a prolonged labor. The 

2 with contracted funnel type pelvis were delivered by cesarean section. 
Of the 6 with simple flat pelves, 4 were delivered by cesarean section, one 
by mid-forceps, and one bj’' version. All the mothers did well, but we lost 

3 of the babies, one stillbirth from intracranial hemorrhage, one prema- 
ture, and one from a complicating enterocolitis. 

We had 75 patients in whom the temperature was 100.4 or over on two 
successive days exclusive of the day of delivery, an uneorreeted morbidity 
of 7.7 per cent. In 25 of the eases the temperature was due to the follow- 
ing complications : pyelitis 4, ej'stitis 1, thrombophlebitis 1, upper respira- 
tory infection 6, bronchopneumonia 3, catarrhal jaundice 1, ulcerative 
colitis 1, and wound infection in abdominal deliveries 2. We had only 11 
cases of cracked nipple and one breast abscess. We attribute this good re- 
sult to the short nursing periods at long intervals in our obstetric care dur- 
ing the first few days postpartum. In our opinion the most common cause 
of cracked nipple is suction on an empty breast. 

Four maternal deaths occurred, an uncorrected mortality of 0.4 per 
cent. The features of these were as follows : 

Case 1. Ruptured uterus. — The pntient was brought in to the hospital iu severe 
shock. She had been under the care of a private physician and apparently in normal 
labor at home. Members of the patient’s family saw the doctor give the patient a 
hypodermic injection. A few minutes later the doctor came out ‘ ‘ in great excitement ’ ’ 
and told the family that the patient had had a convulsion (?) and that she must be sent 
to a hospital at once. The patient delivered while she was being prepared in the labor 
room. The delivery was followed by a profuse hemorrhage. One of my associates ex- 
pressed the placenta and packed the uterus and vagina. An infusion was started but 
the patient died. Postmortem examination showed a laceration of the cervix extending 
into the body of the uterus. 

Case 2. — Upper respiratory tract infection and prolapsed cord. Patient entered 
the hospital with prolapsed cord. She had a bad ' ‘ cold, ’ ’ and was not in labor. For 
some unexplainable reason, one of my associates replaced the cord and packed the cervix 
and vagina although the cord was not pulsating. When the patient’s pulse rose to 148 
and the temperature to 101.8°, the following day he ' ‘ added insult to injury ’ ’ by doing 
a version and extraction. The next day the patient showed definite symptoms of bron- 
chopneumonia and died four days later. Although the patient might have died from her 
bronchopneumonia, the operative bungling did not help her any. 

Case 3. Eclampsia. — A para ii, who had no prenatal care, suddenly began to vomit 
and had three violent convulsions. Sl»e was admitted in deep coma and never recov- 
ered consciousness. Delivery took place two hours after admission but her condition 
did not improve and she died two days later. 

Case 4. Eclampsia.~A para i, seven months pregnant. Patient had no prenatal 
care although she gave a history of vomiting and headache since the third month of her 
pregnancy. Three days prior to admission she developed edema of the face and ankles. 


r 



424 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


On admission the diagnosis of threatened eclampsia was made. Her urine showed a 
heavy trace of albumin, and a few hyaline and granular casts. Her blood chemistry 
was practically normal; her blood pressure was 198 over 130. She was put in a special 
eclampsia room, on a Carrell diet and eliminatives. Three daj's after admission she 
had a convulsion. On a modilied Stroganoff treatment she seemed to improve; her 
mind was clear and she had no convulsions for five days. Then several convulsions 
came in rapid succession. Labor was induced with a Voorhees ’ bag and she was de- 
livered the same day. However, she went into coma and died two days later. I do not 
know exactly where we made our mist.akc, but I feel that this patient might have been 
saved by more radical treatment. 

SUM JI ARY 

A series of nearly a thousand eases tvas delivered in a munieipal hospital 
under strictly conservative obstetrics with a total operative incidence of 
less than 10 per cent, a cesarean section incidence of 0.6 per cent, an nn- 
correeted maternal inortalitj’’ of 0.4 per cent, and an uncorreeted morbidity 
of 7 .7 per cent. If we eliminate the eases of ruptured uterus and fulminat- 
ing eclampsia (both outside eases Avhieh were brought to the hospital in 
extremis) , our mortality was only 0.2 per cent. If we eliminate all non- 
obstetric causes our morbiditj^ rate Avas 5 per cent. 

In conclusion I Avish to thank my former resident. Dr. Jacob Clahr, Avho 
has gathered and classified this material for me. 

ABSTKAOT OP DISCUSSION 

DE. GEOEGE W. KOSMAK. — Dr. Aranow is to be commended for developing in 
his staff the conservative attitude of mind which is reflected in such satisfactory re- 
sults. We need more presentations of this kind to convince us that a conservative 
course in obstetrics is the proper one to pursue. I think his statistics of operative in- 
cidence probablj' measure up lower than those of any other service in the city that I 
know of, and particularly in the public hospitals. 

It has seemed to me, after a study of the puerperal mortality figures that are now 
being prepared by the Committee of the New York Academy of kledicine, that some 
radical steps will have to be taken in the near future to evaluate the work of the men 
on obstetric services. In other words, we vrtll have to make an accounting in the very 
near future of the individual operator ’s work and to evaluate his standing, ability, and 
competency by the results that he produces. It may seem a little bit extreme perhaps 
to call in an accountant to judge the medical problems, but that is really the only way 
to know whether a man is doing good work or not, and the day will come in the very 
near future when services are going to be judged by the capacity of the individual 
w’orkman. That has not as yet been attempted in this country, although it is widely 
practiced abroad. When we have institutions with an operative incidence of 33 to 
50 per cent, ■with a correspondingly high mortality, it seems necessary to make some 
analysis of the individual operator’s ■work in those particular hospitals, and until that 
evaluation is done and until 'we can definitely determine whether it is fair for any man 
to have such a high mortality in obstetrics as ■we find some of our New York men are 
having, then I think vfe are not going to improve our maternal mortality statistics. 

DE. B. P. WATSON. — ^It struck me that the incidence of abnormal pelves was ex- 
tremely small, much smaller, for instance, than we have at the Sloane Hospital. The 
reason for this may be that we select our patients, taking those who show abnormalities 
of any kind in preference to those who appear normal. Our operative incidence also is 
much higher. 



ARANOW: year’s SERVICE IN OBSTETRICS 


425 


It is a very good thing indeed to have this presentation made, shovring that there 
can be such a low operative incidence as 9 per cent. We know that in some clinics, as 
for instance in the W est End Maternity Hospital, London, the operative incidence is as 
low as 3 per cent. There is no doubt that in some of our hospitals the operative inci- 
dence is unnecessarily large. 

Perhaps the only criticism I have to make is in regard to Dr. Aranow’s treatment 
of eclampsia. Why does he induce labor in the presence of active eclampsia when he is 
otherwise so conservative? I believe that when a patient is actually having convulsions 
it is probably better to leave the labor severely alone. 

DR. HARRY ARANOW. — Dr. Watson’s criticism is well taken. However, these 
cases did not have any more convulsions. We control the convulsions with the Stro- 
ganoff method and then wait to see whether they will clear up, if they do not, we put 
in a bag. 

I do not doubt for a minute that there were a great many more cases of abnormal 
pelves in this series. Evidently a great many who delivered normally were passed by 
without being detected. 


Unterberger, and Kirsch: Attempts to Influence the Sex Ratio Among Rabbits 

According to the Procedure of Unterberger. Monatschr. f. Geburtsh. u, Gynak. 

91: 17, 1932. 

The authors attempted to verify experimentally Unterberger ’s contention that 
the use of sodium bicarbonate before intercourse results in a higher proportion of 
males among human beings. Rabbits were used for the experiments because the 
influence of the vagina can be definitely determined before coitus. In some cases 
sodium bicarbonate was instilled into the vagina just before the sexual act and 
and in other cases, lactic acid was used. It has not been decided as to how 
alkalies effect spermatozoa but it may be that the male-producing spermatozoa are 
made to increase their motility and therefore reach the ovum first. The female- 
producing sperm are certainly not destroyed but are only inhibited and therefore 
do not reach the ovum as quickly as the other sperm. However, they may fertilize 
ova which are expelled late. In spite of the latter fact the authors found that 
one animal before any change was made in the vagina gave birth to 28 males 
and 56 females. On the other hand, after the use of sodium bicarbonate, she gave 
birth to 80 males and 41 females. If all the data are collected after the use of 
sodium bicarbonate there resulted 142 males in contrast to 65 females, 

J. P. Greenhill. 



A SURVEY OP CESAREAN SECTIONS PERFORMED IN 
PHILADELPHIA DURING 1931® 

Clifford B. Lull^ M.D., Philadelphia^ Pa. 

^"T^HERE have appeared in the literature during the past few years, re- 
ports of surveys made in ditferent cities of the United States on the in- 
cidence and mortality of cesarean seetion. The Council of the Phila- 
delphia Obstetrical Soeietj’’ decided to make this problem the subject of an 
annual study. I was selected to make this survey for the year 1931. Dr. 
Barton Cooke Hirst and Dr. Phillip Williams were asked to serve in an ad- 
visory capacity and their aid and advice have been most graciously given. 
Without the cooperation of the chiefs of the Obstetrical and Gjuiecological 
Services and the various hospitals record rooms, this study would have 
been impossible, and I ivish to thank them for this assistance. Evei-y hos- 
pital in the city limits has been surveyed and we believe this includes the 
record of eveiy cesarean operation done in the city of Philadelphia during 
this period. The number of births and maternal deaths have been checked 
with the aid of the Bureau of Vital Statistics and tlie Maternal Welfare 
Committee of the Philadelphia County Medical Society. I also wish to 
thank Dr. Charles Gordon of Brooklyn for his aid in the preparation of 
the blanks for this study. 

As this is entirely an impersonal survej’-, each hospital has been given a 
number and they are so recorded in Table I. No effort was made 
to list the operator in each case. Careful inquiry makes me believe that 
although we are still, and always wdll be inflicted ■with the occasional op- 
erator, most of these patients have been operated upon by a trained man or 
under the supervision of one of the attending obstetricians. It might also 
be stated that the uterus and its appendages are still to a certain extent, 
the playground of the general surgeon. 

In some surveys that have been made, all hysterotomies done before the 
thirty-fourth week of gestation have been excluded. In this study, all 
hj^sterotomies irrespective of the time done, have been tabulated. 

Table I lists each hospital separately with the total number deliveries, 
number of cesarean sections done, and the percentage incidence. The high- 
est incidence. No. 34 with 42 deliveries for the year, 7 cesarean sections, 
percentage incidence 16.6, had 0 death ; No. 29 with 194 deliveries, IS 
cesarean sections, and a percentage of 9.2 had no deaths; No. 27, 124 de- 
liveries, 9 cesarean sections, percentage 7.2, had 1 death ; and No. 6, 43 de- 
liveries, 3 cesarean sections, percentage 6.9, 1 death. Nine hospitals with 
a total number of 1329 deliveries, report no cesarean operations done dur- 
ing the year 1931. 

'Read at a meeting of the Obstetrical Society of Philadelphia, May 5, 1932. 

426 



LtJLl,; CESART5AN SECTIONS 


427 


Tablb I 



NO. 

NO. 

PEH. CENT 


NO. 

NO. 

PER CENT 

HOSPIT.\L 

DELI^^SRIES SECTIONS 

INCIDENCE HOSPITAL DELIVERIES SECTIONS 

INCIDENCE 

1 

264 

2 

0.75 

25 

12 

0 

0 

2 

142 

0 

0 

26 

449 

19 

4.2 

3 

135 

0 

0 

27 

124 

9 

7.2 

4 

401 

7 

1.7 

28 

82 

3 

3.6 

5 

49 

0 

0 

29 

194 

18 

9.2 

6 

43 

3 

6.9 

30 

2054 

91 

4.4 

7 

500 

S 

1.6 

31 

1427 

36 

2.5 

S 

1308 

9 

0.68 

32 

553 

21 

3.7 

9 

334 

6 

1.7 

33 

512 

7 

1.3 

10 

650 

1 

0.15 

34 

42 

7 

16.6 

11 

53 

1 

1.8 

35 

15 

0 

0 

12 

570 

10 

1.7 

36 

520 

16 

3.0 

13 

1523 

31 

2.0 

37 

390 

12 

3.0 

14 

934 

39 

4.1 

38 

463 

3 

0.64 

15 

1035 

26 

2.5 

39 

711 

11 

1.5 

16 

816 

16 

1.8 

40 

462 

6 

1.2 

17 

458 

0 

0 

41 

144 

5 

3.4 

18 

246 

7 

2.8 

42 

654 

5 

0.76 

19 

179 

4 

2.2 

43 

603 

24 

3.9 

20 

53 

0 

0 

44 

864 

26 

3.0 

21 

750 

17 

2.2 

45 

396 

3 

0.75 

22 

90 

2 

2.2 

46 

452 

0 

0 

23 

881 

36 

4.0 

47 

13 

0 

0 

24 

961 

26 

2.7 





Table II 


Births 

in City 




35,284 



Births 

occurring in, hospital 



23,511 



Total number cesarean sections 


573 



Per cent incidence in entire birth rate 


1.6 



Per cent incidence in hospital delivery 


2.4 



Table II sboivs the total number of births reported in the entire city, the 
total number of births in the hospital, ivith total number of cesarean sec- 
tions, percentage incidence of cesarean sections born in reference to hos- 
pital deliveries and entire city birth rate. Attention is called to the large 
number of hospital confinements occurring in Philadelphia. In this year ’s 
Year Book of Obstetrics and Gynecology the percentage of home deliveries 
as reported in an abstract was commented upon by Doctor DeLee as being 
higher than he himself had found. He made the note that his idea was that 
about 50 per cent of all women confined were in a hospital at that time. As 
is seen by our figures, a much higher percentage were confined in hospitals. 

Table III shows the number of primigravida and multigravida patients 
delivered by the abdominal method. 


Table III 


Number cesarean sections 573 

Primigravida 284 

Multigravida 289 



428 


A.:mERICAN journal op obstetrics and GA'NECOLOGY 


Table IV lists tbe ntimber of patients whose membranes bad ruptured 
before operation ; those that had been given a test of labor ; those operated 
upon at the time of election, in other words before the onset of labor ; those 
having been examined vaginally, and five cases where one or more attempts 
had been made at vaginal deliveries before admission to the hospital. The 
number of vaginal examinations made varied from one to ten. Of the five 


Table IV 


Membranes ruptured 
In labor 
Not in labor 
Vaginal examination 
Attempted vaginal deliveries 



Table V. Indications for Operation 


Oephalopelvic disproportion 328 

Placenta previa 42 

Preeclamptic toxemia 29 

Eclampsia 14 

Previous section (no other indication) IG 

Premature separation, normal implanted placenta 19 

Cardiovascular disease 21 

Transverse position 12 

Obstructing tumors 9 

Rigid cervix 6 

Ischiorectal abscess 1 

Uterine inertia 7 

Petal distress 4 

Pulmonar 3 ' tuberculosis 4 

Peeble-minded idiot 1 

Arthritis deformans I 

Sterilization 4 


Exhaustion 

Ruptured uterus (one having previous cesarean section) 
Twin pregnancj’ (large babies) 

Stricture of rectum 
Hepatic toxemia 
Epilepsy 

Brow presentation 
Abdominal pregnancy 
Deformity of hip 
Monstrosity 

Previous complete laceration (repaired) 

Breech (elective) 

Ventral fixation of uterus 
Anus vestibularis 

Previous extensive plastic operation 
Elective 

Tuberculous spine 
Threatened rupture cesarean sear 
Parietal bone presentation 
Cerebrospinal meningitis 
Subarachnoid hemorrhage 
Carcinoma of cervix 

Previous Watkins interposition operation 
Constriction of birth canal 
Bandl's contraction ring 
Bicornate uterus 


4 

3 

1 

1 

1 

1 

6 

1 

2 

3 

2 

7 

3 

1 

2 

6 

1 

2 

1 

1 

1 

1 

1 

1 

1 

1 






LULL.; GESAREA.N SECTIONS 


429 


cases ^Yllere a definite record ivas obtainable of attempted vaginal delivery, 
three patients died. Detailed account of these will be made later. 

The term eephalopelvic disproportion has been used to include all cases 
of absolute contraction of the pelvis and those borderline cases where the 
size of the fetal head was too large for the pelvic inlet. TJnder previous 
cesarean section are included 16 cases in which the first cesarean section 
was done for an indication such as placenta previa or premature separa- 
tion, and where the indication at the time of the present operation was only 
the fact that the patient had previously been operated upon. A further 
study of the cases having previous cesarean sections performed upon them 
will occur later. Obstructing tumors of which there were 9, include fibro- 
myomas of the uterus and the tumors of the appendages and birth canal 
which caused obstruction. The 4 cases listed under stei'ilization, had no 
indication other than the fact that it was desirous of performing this op- 
eration because of some constitutional or mental condition present in the 
patient. Under the head of exhaustion there occurred 4 qases. These 4 
cases were given long tests of labor but made no progress as far as dilata- 
tion of the cervix and descent of the presenting part were concerned. Of 
the 3 patients with ruptured uterus, only 1 had had a previous cesarean 
operation. The twin pregnancy occurred in a patient having two large 
children with no fetal part at the pelvic brim and tremendous distention 
of the uterine cavity. Three monstrosities were such that vaginal delivery 
would have meant more traumatism to the maternal soft parts. There 
were? cases of breech presentation where the babies were large and where 
it was elected to deliver by cesarean section because of the possibilities of 
fetal injury. The previous extensive plastic operations were such that 
vaginal delivery ivould have been accomplished -with a great deal of diffi- 
culty. Only 6 cases in this series should be classified as elective operations 
and all of these, although they did not present pelvic deformities or the 
ordinary indications for abdominal delivery, had had previous children 
with loss of the child due to difficult and prolonged labors. Tavo patients 
who previously had had a cesarean section appeared to have symptoms of 
rupture of the scar, but at operation it Avas found that the scar Avas intact. 


Table VI. Operations Pone 


High 

458 

Loav 

103 

Celiohysterectomy (Porro) 

10 

A^aginal hysterotomy 

1 

Abdominal pregnancy 

1 


It is interesting to note that by far the vast proportion of cesarean sec- 
tions done in the city of Philadelphia were of the so-called classical t 3 q)e, 
458 being by this method and onb^ 103 by the low method. A discussion of 
the mortality rate in these tAAm classes of cases is contained in Table XYI. 
A great deal has been Avritten about the advisability of performing the 


430 


AJIERICAN JOURNAIi OP OBSTETRICS AND GYNECOLOGY 


low operation routinely, but as seen from the above statistics, this view has 
not been accepted by most of the obstetricians in this city. We are all con- 
vinced that it is unquestionably an operation which every obstetrician 
should be qualified to do, but up to the present time it has not seemed ap- 
propriate by the majority to accept it as a routine procedure. A further 
discussion of the advisability of performing this operation more frequently 
will be taken up under the discussion of the mortality. The one patient 
Avith abdominal pregnane}^ ivho ivas operated upon, recovered. 


Table Vlt. Incidental Operations 


Sterilization 

85 

Appendectomy 

4 

Salpingo-oophorectomy 

5 

Myomectomy 

17 

Herniorrhaphy 

2 


In this group of 573 patients operated upon, 85 had sterilization opera- 
tions performed. The methods of sterilization varied according to the in- 
dividual operator and the indications were mostly one or more previous 
cesarean operations. Salpingo-oophorectomies were performed upon 5 pa- 
tients Avho had complicated ovarian cysts. Of the 17 myomectomies, the 
majoritj" ivere done incidental to the cesarean section and were not the pri- 
mary cause of dystocia. The 2 herniorrhaphies Avere for umbilical hernia 
and for ventral hernia in an old abdominal scar. 


Table VIII. Anesthesia Used 


Gas ether 

311 

Ether 

154 

Local 

46 

Nitrous oxide 

43 

Spinal 

14 

Ethylene 

5 


Table VIII is a resume of the types of anesthesia used. Gas oxygen 
ether sequence Avas the one most generally given. Only 46 of these cases 
Avere done under local, a method which I believe is becoming more and more 
popular. Of the 14 cases done under spinal anesthesia, 2 patients died be- 
fore the operation was started. The reason that ethylene Avas not used 

Table IX 


Live births oO- 

Stillborn or died •vvitlmi a few days 74 

3 sets of twins in 573 cases 
Total babies '’76 

Fetal mortality 12.8% 

Unavoidable fetal deaths 36 

Corrected fetal mortality 6.2% 




LULL; CESAREAN SECTIONS 


431 


more frequently seems to be due to the fact that most of the hospitals had 
discarded its use because of its dangerous properties. 

Table IX shows the number of fetal deaths. In order to arrive at the 
corrected fetal mortality, 36 cases ivere subtracted from the total baby 
deaths, 74. Among the 36 cases were all babies born before the eighth 
month and monstrosities which would have been impossible to sur- 
vive after any type of delivery. The remaining 38 were mostly babies 
who had been subjected to long labors before cesarean section was done. 
There may have been a few of these 38 which, if a more detailed report 
were given, could have been excluded from the fetal mortality. 

Table X. Previous Sections 


No. having previous cesarean section 107 

No. with previous cesarean section as only indication 11 
No. operated upon, at time of election 79 

No. in labor when operated upon 28 

(One 16 hours, one 24 hours, rest 2 to 6 hours) 

Deaths in this group (In labor 16 hours) 1 


Attention is called to the fact tliat there were only 11 patients in this 
group of 107 who were operated upon at this time because they had had 
previous cesarean sections with no permanent indication for the opera- 
tion. In other words, these 11 patients had had the first cesarean section 
because of central placenta previa, premature separation, or toxemia. At- 
tention is also called to the fact that practically none of these patients had 
any long labor before operation, 79 being operated upon at the time of 
election. As there was only one death in this group, I feel that it again 
demonstrates the advisability of decision in certain types of cases before 
the onset of labor. 

Table XI 


Total number of births in all hospitals 23,511 

Total number of cesarean sections in all hospitals 573 

Number of hospitals having no deaths 25 

Total number of births in these hospitals 8,859 

Total number of cesarean sections in these hospitals 184 

Per cent incidence of all births in these hospitals 37.6 

Per cent incidence of all cesarean sections in these hospitals 32.1 


Table XI shows that there were 25 of the 47 hospitals which had no 
deaths from the operation and in these 25 hospitals, 32.1 per cent of the 
total number of operations was performed. Most of this group of course 
include several of the smaller hospitals, but there was also included in this 
number several hospitals where a fairly large number of operations were 
performed without any maternal mortality. 

Table XII gives a fairly reasonable index of the incidence of cesarean 
section and incidence of deaths occurring in the other hospitals. 





432 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


Table XII. Hospitals Haying Deaths 


HOSPITAL 

NO. BIRTHS 

NO. SECTIONS 

PER CENT SECTIONS 

DEATHS 

PER CENT DEATHS 

6 

43 

3 

6.9 

1 

33.3 

7 

500 

8 

1.6 

1 

12.5 

8 

1308 

9 

0.68 

1 

11.1 

14 

934 

39 

4.1 

3 

7.0 

15 

1035 

26 

2.5 

3 

11.5 

16 

816 

16 

1.9 

1 

6.2 

18 

246 

7 

2.8 

1 

14.2 

19 

179 

4 

2.2 

1 

25.0 

21 

750 

17 

2.2 

2 

11.7 

22 

90 

2 

2.2 

1 

50.0 

24 

961 

26 

2.7 

1 

3.8 

26 

449 

19 

4.2 

1 

5.2 

27 

124 

9 

7.2 

1 

11.1 

30 

2054 

91 

4.4 

6 

6.5 

31 

1427 

36 

2.5 

O 

5.5 

36 

520 

16 

3.0 

2 

12.5 

37 

390 

12 

3.0 

2 

16.6 

39 

711 

11 

1.5 

2 

18.1 

40 

462 

6 

1.2 

2 

33.3 

42 

654 

5 

0.76 

1 

20.0 

43 

603 

24 

3.9 

2 

8.3 

4o 

396 

3 

0.75 

2 

66.6 

Totals 

14652 

389 

2.6 

39 

10.0 


Table XIII 


Total cesarean sections 573 

Total maternal mortality 39 

Per cent incidence of maternal mortality 6.8 


A maternal mortality of 6.8 per cent is the result in the entire city which 
includes all tj^pes of operations. 


Table XIV. Mortality in Other Surveys 


CITY 

NO. SECTIONS 

NO. DEATHS 

PER CENT DEATHS 

Cleveland 

1047 

75 

7.15 

Brooklyn 

1805 

128 

7 

Los Angeles 

1550 

73 

5.1 

Philadelphia 

573 

39 

6.8 

Totals 

4975 

315 

6.3 


Table XIV is a summary of the survey done in three other cities to whieh 
has been added this present survey in Philadelphia. The maternal mor- 
tality of 6.8 per cent in Philadelphia compares with the other surveys 
favorably, but as this work was only carried out over a period of one year 
the total number of cases is not sufficient to be compared with the other 
totals. 

Leading the causes of maternal deaths is sepsis. This classification was 
made as simple as possible and also as accurate as could be obtained from 




LULL: CESAREAN SECTIONS 


433 


Table XV. Causes op Mateenal Deaths 


TOTAL PEE CENT INCIDENCE 

Sepsis 

18 

46.1 

Hemorrhage and shook ■ ' 

11 

28.2 

Cardiac failure 

2 

5.1 

Uremia 

1 

2.5 

Spinal anesthesia 

2 

5.1 

Late hepatic toxemia 

1 

2.5 

Embolism 

1 

2.5 

Nephritic toxemia 

1 

2.5 

Cerebrospinal meningitis 

1 

2.5 

Pneumonia 

1 

2.5 


the records. A large number of patients unquestionably died from sepsis 
were listed as cardiac deaths, with the word peritonitis rather in the back- 
ground. Where there was no evidence of cardiac disease preceding the 
operation upon the patient, the cause of death was finally put down as 
sepsis. Almost one-half the mortality came in this group. The one case 
of embolism occurred on the eleventh day following operation in a pa- 
tient who was apparentlj'' making a normal recovery. The case of cerebro- 
spinal meningitis was moribund on admission to the hospital and had a 
cesarean section done in the interest of the child. Under the heading of 
hemorrhage and shock there were included the 5 cases of eclampsia ; the 
patients either died on the table or within a few hours afterward. 


Table XVI 



TOTAL 

DEATHS 

PEE CENT MOETALITY 

No. of classical operations 

458 

31 

6.7 

No. of low operations 

103 

4 

3.8 

No. of celiohysterectomies 

10 

4 

40.0 

Total number of deaths 


39 



Table XVI shows the maternal mortality occurring in various types of 
operation and as is seen in this group, the percentage maternal mortality 
is 50 per cent less in low cervical section when compared with the high 
operation. Skeel and J ordan in their most recent survey of cesarean sec- 
tions in Cleveland reported a number of other individual surveys with a 
comparison between the classical and the cervical operation. Their con- 
clusions are that the cervical section mortality averages a little less than 
one-half that of the classical section. They have also shown that the lios- 
pital having the highest percentage of cervical operations also had the 
lowest total cesarean section mortality. Although a separate tabulation 
has not been made of the aforementioned question, the hospital having the 
lowest maternal mortality with a fairly large number of operations done, 
was an institution in which the selection of the case for the classical and 
the low operation seemed to be done very accurately. My final conclusions 


4:34 A.JIERICA]Sr JOURNAL OP OBSTETRICS AND GYNECOLOGY 

in looking over this problem from this standpoint are that there is still a 
place for the classical operation, and as has ahvaj^s been saidj the mor- 
tality will always be greatest where the poorest judgment is used in the 
selection of the patient for any tj^ie of_ abdominal delivery. 

According to these statistics the operation of eeJioliysterectomy carries 
a definitely higher maternal mortality. 


Table XVII. Indications for Operation in the 39 Fatal Cases 



total cases 

mortality 

PER CENT MORTALITY 

Cephalopelvic disproportion 

328 

' 17 

5.1 

Ruptured uterus 

3 

2 

66.6 

Eciampsia 

14 

o 

35.7 

Preeclamptic toxemia 

29 

3 

10.3 

Brow presentation 

G 

2 

33.3 

Placenta previa 

42 

3 

7.1 

Premature separation 

19 

3 

15.7 

Cerebrospinal meningitis 

1 

1 


Cardiac disease 

21 

2 

9.5 

Uterine inertia 

7 

1 

14.2 


Table XVII inelndes tlie 39 fatal cases ivith the total number of eases 
in each incidence, allowing us to figure the percentage mortality in these 
various indications. Attention is called to the fact that there were 14 pa- 
tients wlio had eclampsia operated upon with 5 deaths, a mortality of 
35.7 per cent. Also there were 21 patients operated upon because of 
cardiac disease with only 2 deaths. Both of tliese fatal cases evidently 
had very serious cardiac disease and died within forty-eight hours after 
operation. The delivery of women with severe cardiac damage by cesarean 
section, particularly under local anestliesia, has become more and more 
popular. 

In Table XVIII there are sevei-al typical pictures of the reason for 
death following cesarean section. For example : a patient in labor twenty- 
six hours, 4 vaginal examinations, membranes ruptured for fourteen 
hours, classical operation done; one would expect the natural outcome, 
death from sepsis. Attention is also called to the fact that there is a mor- 
tality from cesarean section even when the patient is not in labor, has had 
no vaginal examinations, and the membranes have not ruptured. One of 
these patients who had been in labor twenty-four hours, membranes hav- 
ing ruptured only two hours before operation and supposedty not having 
had any vaginal examinations, had the classical operation performed and 
died of sepsis. Just before death it was found that an attempt had been 
made to delwer this patient on the outside, of which there was no histoi'y 
at the time of operation. The patient avIio died of hepatic toxemia was 
evidentty one of these rare hepatic types of late toxemia which are usually 
fatal and died of the liver damage fifteen days following section. 

The first case, brow presentation, evidently had severe hemoi-rhage at the 




LULL: CESAREAN SECTIONS 


435 


Table XVIII. E£sum6 of Fatal Classical Operations (Total 31) 


HRS. 

HOURS VAG. MEMB. 


indication 

LABOR 

EXAM. 

RUPT. 

CAUSE OP DEATH 

Cephalopelvic disproportion 

35 

0 

12 

Cardiac failure 

Cephalopelvie disproportion 

48 

0 

yes 

Sepsis 

Cephalopelvic disproportion 

26 

4 

14 

Sepsis 

Cephalopelvic disproportion 

48 

2 

0 

Sepsis 

Cephalopehdc disproportion 

0 

0 

0 

Sepsis 

Cephalopelvic disproportion 

48 

2 

24 

Sepsis 

Cephalopelvic disproportion 

62 

0 

0 

Sepsis 

Cephalopelvie disproportion 

48 

3 

0 

Sepsis 

Cephalopelvic disproportion 

0 

0 

0 

Sepsis 

Cephalopelvic disproportion 

0 

0 

0 

Sepsis 

Cephalopelvic disproportion 

24 

0 

2 

Sepsis — attempt to deliver at home 

Cephalopelvic disproportion 

21 

0 

0 

Spinal anesthesia, before operation 

Cephalopelvic disproportion 

0 

0 

0 

Sepsis 

Cephalopelvic disproportion 

72 

4 

0 

Shock and hemorrhage 

Eclampsia 

24 

3 

? 

Shock and hemorrhage 

Eclampsia 

8 

1 

? 

Shock and hemorrhage 

Eclampsia 

0 

0 

0 

Spinal anesthesia, before operation 

Eclampsia 

0 

0 

0 

Shock and hemorrhage 

Eclampsia 

0 

0 

0 

Shock and hemorrhage 

Preeclamptic toxemia 

0 

0 

0 

Hepatic to.vemia, 13 days 

Preeclamptic toxemia 

0 

0 

0 

Shock and hemorrhage 

Broiv presentation 

36 

5 

? 

Sepsis 

Placenta previa 

6 

0 

0 

Embolism, 16 days 

Placenta previa 

12 

0 

0 

Cardiac failure 

Placenta previa 

10 

0 

0 

Shock and hemorrhage 

Premature separation 

12 

0 

0 

Cardiac failure 

Premature separation 

5 

0 

0 

Nephritic toxemia, 11 days 

Premature separation 

0 

0 

0 

Shock and hemorrhage 

Cerebrospinal meningitis 

0 

0 

0 

Cerebrospinal meningitis 

Cardiac disease 

0 

0 

0 

Cardiac failure 

Cardiac disease 

0 

0 

0 

Sepsis (cardiac) 


time of operation and died shortly after return from the operating room. 
The patient who had preeclamptic toxemia unquestionably died of gradual 
uremia which was fairly well advanced before operation and in spite of 
emptying the uterus, continued to develop until death ensued on the fourth 


Table XIX. KfisuMfi op Fatal Low Operations (Total 4) 


INDICATION 

HOURS 

UABOR 

VAG. 

EXAM. 

HRS. 

MEMB. 

RUPT. 

CAUSE OF DEATH 

Brow presentation 

29 

0 

0 

Shock and hemorrhage 

Preeclamptic toxemia 

0 

0 

0 

Uremia (fourth day) 

Cephalopelvic disproportion 

70 

1 

72 

Sepsis (1 attempt vaginal delivery) 

Cephalopelvic disproportion 

11 

0 

0 

Sepsis 


day. The test of the advisability of doing the low operation instead of 
hysterectomy was severely tried in the other two cases. The possibilities 
are, that both of these women had entirely too long a test of labor. 


436 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


Table XX. Bfisunfi op Fatal Celiohtsterectomies (Total 4) 



city 

cases 

Cleveland 

30 

Brooklyn 

19 

Los Angeles 

25 

Philadelphia 

19 

Totals 

93 


MATERNAL DEATHS 


RATE PER CENT 


Table XXIII. Comparison op Other Surveys in Eclampsia 


MATERNAL DEATHS 


rate per cent 


Cleveland 
Brooklyn 
Los Angeles 
Philadelphia 


Totals 


LULL,: CESAREAN SECTIONS 


437 


Table XXIV. Comparison of Other Surveys in Preeclamptic Toxemia 


CITY 

CASES 

maternal deaths 

RATE PER CENT 

Cleveland 

66 

3 

4.5 

Brooklyn 

106 

7 

6.6 

Los Angeles 

187 

11 

6 

Philadelplua 

29 

3 

10.3 

Totals 

388 

24 

6.1 


had had everything from bougies and hags to version, forceps, and crani- 
otomy tried before the operation was done. 

Table XXV. Recapitulation op Philadelphia Survey 


Total number birtlis in city 35,284 

Total number births in hospitals 23,511 

Total number of cesarean sections 573 

Maternal mortality of entire births 203 

Maternal mortalit}' of cesarean section 30 

Per cent maternal mortality due to cesarean section 19.2 

Per cent incidence of cesarean section in entire city 1.6 


Tables XXI, XXII, XXIII and XXIV are comparisons with the Phila- 
delphia statistics and those returned from other surveys. 

CONCLUSIONS 

1. A great deal of information concerning the use and abuse of cesarean 
section has been obtained from these statistics. 

2. The incidence of cesarean section for the entire city, we do not con- 
sider to be high. The incidence of cesarean section in a few hospitals seems 
to be a trifle higher than the majority. 

3. The incidence of confinements occurring in hospitals in Philadelphia 
has increased in the last decade. 

4. The indications for doing cesarean section have increased during the 
past few years. However, we believe that this increase in the number of 
indications is justifiable, and that the operation has not been abused except 
that possibly in a few cases listed as cephalopelvic disproportion there 
may have been some instances where the imagination was stretched a 
trifle. 

5. The high or classical operation up to the present time seems to be 
used more extensively than the low operation. This survey bears out the 
fact as has been found in other statistical studies, that the mortality rate 
of the low operation is approximately one-half of the high operation. 

6. Prom the number of incidental operations performed in this group 
of 573 eases, we beliei'-e that most men think it good surgery not to do more 
than the cesarean operation unless it is absolutely necessary. 




438 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


7. Spinal anesthesia is questionably a safe procedure in pregnant 
women at full term, and we believe that the use of local anesthesia will be- 
come more generally advocated. 

8. The fetal mortality in this gi'oup of eases is too high and can prob- 
ably be accounted for bj'’ allowing tlie patient to undergo too severe a test 
of labor before cesarean section Avas decided upon. 

9. Patients having previous cesarean section ivere usually operated 
upon at the time of election, and had the lowest mortality rate. The opera- 
tion of cesarean section done at the time of election irrespective of ivhether 
the high or the low operation is done, is undoubtedty the safest. 

10. One hundred and eighty-four cesarean sections were done in twenty- 
five different liospitals Avithout a maternal death. A careful study of the 
records of some of these hospitals sIioaa's that the judgment of the men in 
charge as to the time to operate upon a patient, the tjqie of operation to be 
done, and the anesthetic to be used, played an important part. 

11. A maternal mortality of 6.8 per cent is about the average throughout 
this country. This unquestionabl 3 ’- could be reduced bj’- more careful judg- 
ment of the time to operate upon a patient, the type of operation done, and 
the anesthetic used. 

12. Sepsis is still the most frequent cause of death in cesarean section 
and AAull still continue to be as long as Avomen are alloAved to remain in 
labor AAuth ruptured membranes, frequent vaginal examinations, and 
classical cesarean section. If the mortality rate as proved by not only 
these statistics, but by those of Amrious other Avritei’s, is one-half that in the 
loAv operation as in the high operation, it Avould seem onlj' feasible that 
more men should adopt this operation into their obstetric armamentarium. 
A great deal probabty depends upon the method of closure of the uterus 
as several men are still doing this so-called classical operation in cases 
Avhere the low operation Avould seem to be indicated, but Avhose results are 
satisfactory. Their good results ai’e probably obtained bj^ the fact that 
the incision is made in the loAver part of the uterus AAotliout dissecting a 
flap, but where the closure of the uterus is A'^ery carefully done. That there 
is still a definite place for the classical operation, I believe to be unques- 
tioned, and unless one is thoroughty trained, a high operation is much less 
likely to be fatal from shock or hemorrhage, but it is perf ectty obvious that 
in a potentialty infected ease the classical operation is not the operation of 
choice. 

13. Once more it is shoAvn that AAmmen AAdio are suffering from eclampsia 
are not suitable risks for abdominal surgery. 

14. In spite of a maternal mortality of 6 per cent, cesarean section seems 
to be the most faAmrable method in the treatment of cential placenta 
previa. 

And finalty, AA*e again reiterate that the mortality rate in cesarean sec- 
tion lies Avith the individual judgment of the operator in the selection of 



LULL: CESAREAN SECTIONS 


439 


the time to do the operation, the type of operation to he done, and the 
anesthetic to be used. 


REFERENCE 

STceel, A. J., and Jordan, F. F. : A Consideration of Cesarean Section, With a Snr- 
vej of 1047 Cases in the Cleveland Registration Area in Five Years, Am. J . Obst. & 
Gynec. 23: 172-187, 1931. 

1731 Pine Steeet. 


ABSTRACT OP DISCUSSION 

DR. BARTON C. HIRST. — This survey is useful in calling the attention of the 
profession, and, I hope, of the laity also, to the fact that cesarean section ought not 
to be resorted to as lightlj’ as it so often is, especially in some of the smaller com- 
munities of the country. 

I know personally of a case which may serve as an example. A young primigravida 
in perfect physical condition had a breech presentation. On entering the hospital of a 
small city she was informed that she was to have a cesarean section. Apparently the 
sole indication was the breech presentation. During the night of the labor I was called 
upon repeatedly to sanction the section, but tlie next morning, just as I entered the 
hospital the baby was born, as I had expected. 

I believe that cesarean section has a very important place occasionally in the treat- 
ment of eclampsia. 

We had some interesting experiences with it in the University Maternity Hospital. 
During five years we had 87 eases. In that number of 87 eclampsia cases, we had 17 
resisting all the ordinary methods of treatment, but all recovered, although thej' were 
the worst in the list. 

DR. G. W. OUTERBRIDGE. — A patient recently seen in a small community had 
previously had a baby by a perfectly normal delivery. She became pregnant again, 
and went to a general surgeon who had a small private hospital. He began talking 
cesarean section. She did not see why, but he told her that during the previous year 
he had done 73 cesarean sections. She was in labor a few hours, and a cesarean section 
was done. She was one of four cases in this small private hospital at the same time, 
one of whom died. 

DR. EDWARD A. SCHUMANN. — I question very much, not the value of these 
surveys, but their interpretation. 

To any one of us, there may come the primipara with short pelvic measurements 
and in whom a careful obstetric examination, just before term, discloses the probability 
of a long and difficult labor with its attendant maternal mortality. In considering the 
possibility of elective section in such a patient, one should certainly not be compelled 
to regard as a contraindication the high mortality as given in this and other survey's. 
When section is grouped as a single procedure without regard to the time at which the 
operation is performed, the condition of the patient and the ability of the operator, I 
feel that the statements are most misleading because the actual mortality rate of elec- 
tive cesarean section in skilled hands is so low as to be practically negligible. Again in 
the comparison of the low operation with the classical we must remember that the 
low procedure is much more generally employed by specialists in obstetrics while the 
simpler classical operation is performed by those less skilled and by occasional 
operators. Here again, then, I feel the comparison of mortality is erroneous. With re- 
gard to the place of cesarean section in eclampsia, I maintain that it has a very distinct 
though limited place and that in cases where delivery by the vaginal route offers great 
difficulty and where no improvement in the toxic condition is observed after a reason- 



440 


AMERICAN JOURNAL OF OBSTETRICS AND GTNECOLOGT 


able application of sedative and eliminative measures, cesarean section Avitli local anes- 
thesia offers the best lioim for a successful outcome. 

DE. T. L. MONTGOMEET. — The maternal mortality in 9,823 cesarean deliveries 
reported from various metropolitan areas in the United States shows that the opera- 
tion is nearly seven times more dangerous than natural delivery. In the United States 
the general maternal death rate is 6.2 per 1000 live births. The maternal death rate 
for abdominal delivery, however, is nearly 70 per 1000 live births. It is interesting to 
note that the maternal mortality rate for Philadelphia in 1931 corresponds precisely 
with the average mortalit}’ rate reported in these several metropolitan areas. 

In Germany, in 1928, 4,450 cesarean sections were performed with 316 maternal 
deaths, a maternal mortality of 7.1 per cent. 

In a series of 16,296 cesarean sections which have been reported from this country 
and from Europe, there were 1,059 maternal deaths or a mortality rate of 6.5 per cent. 


CYSTIC FIBROID WEIGHING FORTY-SEVEN POUNDS AND 
SIMULATING AN OVARIAN CYST 

J. P. Greenhill, M.D., Chicago, III. 

Attending Gynecologist, Cool; County Eospital 

I N AN article on "Cj’stie Fibroid With Twisted Pedicle, Simulating an Ovarian 
Cyst,” which appeared in the January, 1932, issue of the American Journal or 
Obstetrics and Gtnecologt, Spivack and Pilot give a detailed description of this 
condition and cite the few cases reported in the literature where the tumors were 
very large. Because of the rarity of the occurrence of large uterine fibrocysts, the 
difSculty in making a correct clinical diagnosis and the relatively large number of 
deaths which occur without operation due to disturbances in circulation, breathing 
and cachexia, I am reporting the following case. 

CASE REPORT 

Mrs. D. McG., colored, aged forty-eight j^ears, was admitted to the Cook County 
Hospital on October 12, 1928, because of a huge swelling in the abdomen. The past 
history was unreliable because of the poor mental condition of the patient, but it 
was essentially negative. She had never been pregnant. The swelling of which the 
patient complained began about seven years before admission and at first was limited 
to the left side of the lower abdomen. For about five years the growth of this mass 
was slow but during the last two years, the increase in size was rapid and extended 
over the entire abdomen. During the past year a physician performed paracentesis 
about 75 times and he said that each time a few quarts of clear, slightly serous fluid 
was obtained. After each paracentesis, the swelling diminished in size. During the 
past two months, the patient had two paralytic strokes. The first caused paralysis 
of the left side of the body but this cleaved up entirely. The second stroke involved 
the right side and at the time of admission all signs of paralj'sis had disappeared 
except on the face. The patient had menstruated regularly up to four months be- 
fore entry to the hospital. There were no menses after that, and she had never had 
any menstrual disturbances. 

On admission, the patient appeared critically iU. She was markedly emaciated, 
had a foul odor and was disoriented. The temperature was 98.4° F., the pulse rate 
was 112, the respiratory rate was 24, and the blood pressure was 160 mm. systolic 
and 80 mm. diastolic. The right side of the face was paralyzed and the pupils did 



GREENHILL: CYSTIC FIBROID 


441 


not react to light. There was no nystagmus or strabismus. The conjunctival mucous 
membrane was very pale. The nares were partly occluded with dried blood. The 
right corner of the mouth drooped and the patient could not (or would not) pro- 
trude her tongue very far. The teeth were in an abominable condition. Pressure 
over the right supraorbital nerve failed to produce a muscular response, thereby in- 
dicating a lesion involving the right facial nerve. There were no abnormalities in 
the neck except an enlarged thyroid. The apex of the heart was in the fifth inter- 
space in the left midaxillary line. The right border of the heart was at the right 
sternal border and there were systolic murmurs at the apex and at the pulmonic areas. 
The lungs showed diminished resonance and very shallow breathing. 

The abdomen presented an unusual appearance for it was enormously distended 
and deeply pigmented as may be seen in the illustrations. The skin contained 
numerous large striae. The distance from the symphysis pubis to the xiphoid process 
measured 88 cm. (35.2 inches) and the distance from one anterior superior spine to 
the other was 83 cm. (33.2 inches). In about the center of the huge abdominal 
dome was a large, lobulated hernia which was very soft and measured about 15 cm. 



Pig. 1. — Photograph showing distended abdomen, umbilical hernia more clearly and 

also large striae and emaciation. 

(6 inches) in diameter. The top of this hernia included and surrounded the 
umbilicus. Palpation of the abdomen revealed a few large, hard masses of dif- 
ferent sizes, some of which were fixed while others were movable. Percussion and 
succussion revealed a large amount of free fluid in the abdomen. 

On vaginal examination the perineum was found to be markedly relaxed but there 
was no cystocele. The cervix was so high up that it could not be reached. The body 
of the uterus likewise could not be outlined. The diagnosis made was “ovarian 
cyst, multilocular with ascites. ’ ’ 

The urine contained 1-plus albumin and a few hyaline casts. Otherwise it was 
negative. The patient had an outspoken anemia for her red blood count was 
1,000,500 and her hemoglobin was 40 per cent. The white blood cell count was 25,000. 

On account of the patient’s critical condition I of course, deferred operating. 
The hope was to keep the patient in the hospital for a few weeks and to build up her 
general condition by various procedures including repeated blood transfusions. 
However, in spite of our efforts to help the patient she died on October 24 and an 
autopsy was performed by Dr. R. H. Jaffe to whom I am indebted for the autopsy 
record (autopsy No. 716). The main interest in this case report centers about the 
findings in the abdomen. On opening the abdominal cavity there was exposed a 



442 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGT 


huge, firm mass wliieh on removal was found to measure 40 cm, (16.0 inches) in 
length, 33.5 cm. (13.4 inches) in height, and 38 cm. (15.2 inches) in width. It 
measured 116 cm. (46.4 inches) in circumference and weighed 21.4 kilos. (47 
pounds). Tlie mass had a smooth, shiny, light, yellowish white surface. Scattered 
throughout were deep purple-gray and yellow-gray roundisli areas each about 2 cm. 
in diameter. On the anterior surface were many dilated and tortuous veins. To the 
upper left quadrant of the tumor there were attached several loops of intestines 
which were very firmly adherent and appeared to he compressed. Numerous small 
cysts varying from 5 to 20 mm. in diameter wore found ne.ar the intestinal adhesions 
and smaller ones were found on the intestines and on the mesentery. 

The huge mass was found to be continuous with the posterior surface of the uterus 
which was compressed low down in the pelvis. The mass extended into the right 
broad ligament, displ.acing the ovary considerabl}’. On opening the large mass, 
about 4 liters of thick, cloudy, dirty, gray-brown, foul-smelling fluid was found in a 



Fig, 2. — Cystic fibroid with adherent intestinal loops after removal. 


huge central cavity. The wall which surrounded the cavity measured 5.5 cm. (2.2 
inches) anterioi'ly and varied from 3 mm. to 20 mm. posteriorly. It consisted of a 
rather firm, grayish white tissue. The internal lining of the cyst wall was formed 
by a dirty gray-brown and gray-green tissue which was covered with membianous 
tags. 

The uterus was 4 cm. long, its wall was 8 mm. thick, and the endometrium was 
pale. The right ovary measured 4.5 by 2 by 0.5 cm. and the left one measuied 3 by 
2 by 0.8 cm. 

The wall of the cystic tumor was composed of smooth muscle fibers which were 
arranged in bundles interlacing in various directions. There were areas of edematous 
loosening of the interstitial tissue and in other places there was much hyaline de 
generation. Near the cavity the tissue was more necrotic and large numbers of 
polymorphonuclear leucocj’tes were seen in the necrotic tissue. 

The other abnormal conditions found at the autopsy are listed in the anatomic 
diagnosis which was as follows: degenerated fibrocystic myoma of the uterus witi 




MANN AND LOWENBURG: SUBMUCOUS MYOMA 


443 


extreme displacement of the abdominal organs, ascending pyelonephritis of the left 
kidney, slight essential hypertrophy of the heart ■with bro-wn atrophy and parenchyma- 
tous degeneration of the myocardium, slight compression atelectasis especially of 
the dependent portions of the lo'wer lobes, fibrous adhesions about the spleen and 
liver, chronic tumor of the spleen -with hyalinization of the capsule, slight cloudy 
S'welling of the liver, diffuse colloid goiter, marked decrease in the lipoid content and 
edema of the suprarenal cortex, chronic cholecystitis and cholelithiasis, catarrhal 
cystitis, multiple subserous fibromas of the fundus of the uterus, atrophy of the 
uterus, umbilical hernia, and marked emaciation, anemia and hydremia. 

185 North Wabash Avenue. 


SUBMUCOUS MYOMA COMPLICATINO THE PUERPERIUM 
A Review of the Literature With the Report op a Case 

Bernard Mann, M.D., F.A.C.S., and Henrietta Lowenburg, M.D., 

Philadelphia, Pa. 

(From the Department of Gynecology of Mt. Sinai Hospital) 

M any articles have been -written, and textbooks give ample space 
dealing -with the question of myomas complicating pregnancy and 
labor. Comparatively little has been written concerning myomas and 
the pnerperium, especially the submucous type, due perhaps to the fact 
that fewer eases come to term, also that patients with submucous myoma 
are apt to be sterile, and if pregnant, are more prone to abort. 

In a recent paper by Watson, giving his experiences of cases in which 
fibroid tumors of the uterus have presented a problem in relation to 
fertility, pregnancy, labor, and the pnerperium, he does not mention the 
presence of a submucous fibroma complicating the pnerperium, nor does 
the discussion of his paper elicit the citation of a case. 

An interesting case presented itself at the Mt. Sinai Hospital that we 
felt would be of sufficient interest to report. 

H. W., -white, aged thirty-t-wo years, placed herself under the care of the senior 
author (B. M.) from the beginning of her present pregnancy. This -was her third 
pregnancy, the first terminating in an abortion at the end of the second month, and 
the second in the spontaneous delivery of a normal living child eleven years ago. 
She began to menstruate at the age of fourteen, ahvays regular, rather free in 
amount and five days ’ duration. She had her last menstrual period October 20, 1930, 
was calculated to be due July 27, 1931. The present pregnancy proceeded unevent- 
fully and labor began at 1 o’clock the morning of August 4, 1931. The patient ar- 
rived at the hospital at 3:40 a.m. The uterine contractions were strong, occurring 
every tvto minutes and lasting sixty seconds. The membranes had ruptured on the 
way to the hospital and before the patient could be properly prepared the child was ’ 
born, weighing 6 pounds, 4% ounces. One ampule of pituitrin was given by hypo- 
dermic injection following the birth of the baby and the uterus seemed well con- 
tracted and firm. Examination revealed no laceration. The bleeding was very 
slight. The placenta was propulsively expelled in thirty minutes, it was carefully 
mspected and found to be intact. One ampule of gynergen was administered intra- 
muscularly and the uterus contracted firmly, remaining below the umbilicus. The 



444 


MMEUIC^USI JOURNAL OF OBE5TETR1CS AND GYNECOLOGY 


first hour postpartum the patient oozed a very moderate amount of blood. Four 
hours after delivery a few larger clots were expelled and after-pains were severe. 
The uterus continued to be well contracted. After waiting forty-eight hours, during 
which time she continued to pass clots and complain of after-pains, we decided to 
explore the uterus. 

Under nitrous oxid oxygen anesthesia a hand was introduced into the uterine 
cavity and a firm, somewhat flattened out globular mass of tissue firmly adherent 
to the anterior uterine wall was encountered. The tumor was with difSculty shelled 
away from the uterine wall and extracted in several pieces. An ampule of gynergen 



Fig-, 1 , — Section of myoma showing poorly preserved muscle fibers (high power). 



Fig. 2. — Section of myoma showing poorly preserved muscle fibers (low power). 


was given intramuscularly. From this time on, all bleeding ceased, and the uterus 
normally underwent the process of involution. Except for a period of twenty-four 
hours following the removal of the tissue, when the temperature was elevated to as 
high as 103° F. She made an uneventful recovery, and was discharged from the hos- 
pital the fifteenth day following delivery in excellent condition. 

Fatliologic Seport . — The specimens submitted consisted of several large pieces of 
tissue of irregular outline. The largest measured 13.5 by 9 by 4 cm., and the others, 
approximately equal in size, measured 8 by 3.5 by 2 cm. All were firm in con 
sistency and were composed of pinkish-white tissue, portions of wliich were infiltrate 
with blood. On sectioning some portions of the interior had a grayish cast. 



MANN AND LO^^^ENBURG: SUBMUCOUS MYOMA 


445 


Microscopically the tissue presented was uterine musculature in varying states of 
preservation. Its fibers exhibited throughout, the hypertrophy incident to the gravid 
state. Many of them showed vacuolization. In some fields the nuclei and protoplasm 
stained fairly well but for the most part they stained poorly, indicating a semi- 
necrotic condition. Large sinuses were present, many of which were filled with blood. 
No placental tissue was found. 

A search through the literature revealed only one such case reported by Gonnet, in 
Lyon in 1912 of a case of a twenty-year-old primipara who underwent a normal 
pregnancy and spontaneously delivered a living child. Four hours after delivery the 
placenta showed no signs of separation. The uterus was firmly contracted and un- 
usually large. A hand was introduced into the uterine cavity and encountered an ad- 
herent placenta. In the course of a manual removal the hand came in contact with 
a hard firm mass which was attached by a pedicle to the uterine wall. The placenta 
was particularly densely adherent to the mass. After the placenta had been ex- 
tracted, Goimet removed the pedunculated tumor from the uterine wall by digital dis- 
section. Pathologic examination proved it to be a submucous fibroma. The patient 
had an uneventful recovery. 

Another case reported by Lepage and Vaudescal in Paris, in 1913, was that of a 
primipara, who after a twelve hour labor, delivered herself of a living child. The 
placenta could not be expressed and a hemorrhage occurred, so profuse that a man- 
ual separation and extraction was resorted to. A large submucous fibroid was 
found occupying the posterior fundal portion of the uterine cavity. It was left 
alone. Several days later the lochia became foul and the patient ran a septic tempera- 
ture. A subtotal hysterectomy was performed and the submucous fibroid was found 
to be infected and necrotic. The patient recovered after a stormy convalescence. 
Spencer reports a patient that bled for eleven days postpartum. The uterus was 
firmly contracted during this time, but reached a slightly higher level than was con- 
sidered normal. He also states that the diagnosis of submucous tumors during preg- 
nancy is difficult. During the puerperium it is easier, but even then they may be 
overlooked. 

Hemorrhage is undoubtedly the commonest symptom. Engstom, Neubner, and 
Troele have found the placenta firmly adherent to a pedunculated tumor. When 
separation occurs hemorrhage is inevitable. Glarner and Wertheim have reported 
postpartum hemorrhages as a result of intramural and sessile growths. Fischmann 
in summarizing the complications of submucous fibroids during the puerperium names 
hemorrhage as the most common. 

Polak states that some submucous tumors cause no symptoms, but do not involute 
with the uterus and are extended. With this extrusion Gemmil reported a partial in- 
version of a uterus. Both Polak and Gemmil report eases that have bled profusely 
witli the delivery of the afterbirth. Pearson, Glarner and Wertheim, Fischmann, 
Engstrom, .Neubner, Troele, and others also believe that intramural and sessile 
growtlis as well as pedunculated grow’ths often cause postpartum hemorrhage. "When 
this occurs, all the authors agree that myomectomy should be done immediately. 


REFERENCES 

IFatsoj!, B. P.: Am. J. Obst. & Gynec. 23: 351, 1932. Gonnet, M.; Lyons med 
118: 491, 1912. Lepage, G.: Et Vaudescal-Bul. Soc. d’osbst. ct de Gynec. de Paris 
2: 43 d, 1913. Spencer, E. G.: Lancet p. 411, February 21, 1920. Gemmil TF. F • 
A^. J. Oust. & Gynec. 18; 827, 1929. Polalc, J. 0.: Surg. Gynec. Obst^ 4S- 2i 
1928. Fischmann, E. W.; Surg. Gynec. Obst. 39: 327, 1924. Engstrom; Quoted by 
Fischmann. Troele: Quoted by Fischmann. Eeuhncr: Quoted by Fischmann 
Glarner: Quoted by Fischmann. Wertheim: Quoted by Fischmann. 

245 South Sixteenth Street. 



TUMORS OF THE ROUND LIGAMENT 
Cybus F. Hoeine, M.D., Baltimore, ]\Iabyland 

(From the Department of Surgery, School of Medicine, University of Maryland) 

K W., aged fifty-four, married, entered the Provident Hospital July 2, 1929, 
• complaining of a "swelling in the lower part of the stomach." The family 
liistory and the past history were negative. The patient started menstruating at the 
age of thirteen years. Regular periods lasted three to four days without excessive 
bleeding or pain. Menopause occurred ten years previous to time of admission. 
She had carried and delivered three full-term babies without instrumentation. 

The physical examination was negative with the exception of the presence of a 
mass in each inguinal region. These masses had been noticed for a period of one 
year prior to admission. The mass on the right side appeared to be about the 
size of an English walnut, sowewhat movable, and not adherent to the overlying 



Pig. 1. — This is a photograph (actual size) of the tumor describeii In the text. 

skin. It was fairly firm in consistency, though apparently cystic. The mass on 
the left side was not quite so large and not so freely movable as the one on the 
right side. It was more or less "doughy" in consistency. Operation was advised, 
after a diagnosis of bilateral hydrocele of the canal of Nuck had been made. 

Both masses were exposed through inguinal incisions under nitrous oxide and 
ether anesthesia. A hydrocele of the canal of Nuck, found on the right fide extend- 
ing down to the fundus of the bladder, was removed in toto. The tumor of the left 
inguinal canal was encapsulated and adherent to the extraperitoneal portion of 
the round ligament. A slightly transparent capsule made us suspicious of an 
incarcerated hernia. An incision made into the capsule set free about an ounce of 
straw-colored fluid. The internal inguinal ring could not be found near the mass 
which was dissected away from the round ligament and enucleated in toto. A careful 
examination was made to determine the presence of scar tissue between the capsule 
of the mass and the anterior parietal peritoneum. There was no scar tissue present. 
The capsule of the tumor was of the same thickness throughout. Fatty tissue re- 
sembling omentum was suspended by a pedicle- within the capsule. The lining of 
the capsule had a serous surface resembling peritoneum. 

The fatty mass may have been embryonic in derivation or it may have been the 

446 



HORINE: TUMORS OF ROUND LIGAMENT 


447 


result of an old strangulation of part of the omentum. If its presence was due to 
an old strangulated omentocele one -would expect to find some scar bet-ween the 
capsule and the parietal peritoneum. This, as mentioned abo-^e, could not be found. 

In addition to this ease, -we have reviewed 36 eases of the different 
types of tnmors of the round ligament which have been reported since 
1914. Prior to 1914, Wells reported 2 eases of fibromyomata in 1865; 
Saenger in 1882 reported 12 eases of fibromyomata in addition to one 
case of his own; Emanuel in 1903 eolleeted 80 eases and Taussig found 
61 cases of tumor reported from 1903 to 1914, in addition to his o-wn 
reported case of sarcoma of the round ligament. 

I have not included the eases of hydrocele in this group but have in- 
cluded two cases of dermoid cysts, one cystic lymphangioma and another 
cyst thought to have been tuberculous. Guyot and others reported 
finding a mass which proved to be an inflammatory lymphatic gland. 
They mention that the presence of glands on the round ligament near 
the horn of the uterus appears to be very rare. 

The average age in this group is thirty-eight years. The age was not 
given in five cases. This corresponds to the average age in other re- 
ported groups of cases. Winckel found one case in a patient seventy-six 
years of age, while the youngest reported case has been recorded by 
Aichel in a newborn child. The youngest case in our group was a child 
five years of age, reported by Dueuing as having a bilateral lipoma. The 
oldest case is Gueullette’s case of Wolff’s tumor in a woman sixty-three 
years of age. This tumor showed malignant degeneration. 

We found 22 cases where the tumor occurred on the right side, while 
9 cases were located on the left side, and 2 cases were bilateral. One of 
the bilateral cases was lipoma and the other fibromyoma. The location 
was not given in 3 cases. Emanuel’s review shows a preponderance of 
tumors of the right side, while Taussig’s report gave almost equal dis- 
tribution. Ward, Kanther, Vercesi, Sams and Walther reported their 
cases as having been intrap eritoneal. 

According to Taussig the symptoms of tumors in this location are very 
slight. A number of this group complained of pain at the site of the 
tumor during menstruation. 

Broun ’s case of adenomyoma and Sserdjukoff’s case of cystic lym- 
phangioma were given as postoperative cases. Calzavara’s ease of osseous 
tumor was thought to have resulted from an old tuberculous infection. 

The diagnosis in practically all of this group Avas made by histo- 
pathologic section. The cases arc tabulated as follows : 


Adenomyoma 

4 cases 

Fibrosarcoma 

2 cases 

Cystic Fibroma 

1 case 

Leiomyoaagioma 

1 case 

Cystic Lympiiangioma 

1 case 

Lipoma 

1 case 

Dermoid Cyst 

2 cases 

Lymph gland in ligament 

1 case 

Fibroma 

6 cases 

Osseous Tumor 

1 case 

Fibroloiomyoma 

1 case 

Sarcoma 

2 cases 



448 


AilERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


Fibromj'onia 5 cases 

Fibromyosarcoma 1 case 

Fibromyxoma 1 case 

Fibromyxolciomyoma 1 case 


Tuberculous Cyst 1 case 

Varicosities 2 cases 

Wolff’s Tumor 2 cases 


REFERENCES 

(1) Aichel; Zenlralbl. f. G3’nak. 1; 57, 1912. (2) Ballin, M.: Harper's Hosp. 

Bull. 1: 1-3, Detroit, 1917. (3) Broun, L.: Am. J. Obst., N. T. 79: 561-563, 1919. 

(4) Calzavara, ]J.; Zentralbl. f. Gynak. 48: 579-581, 1924. (5) Cerneszi, A.; 

Pensiero med. 4: 709-712, 1914. (6) Goscntino, A.: Morgagni, Milano e Napoli 

59: 265-272, 1917. (7) Cullen, T. S.: Bull. Johns Hopkins Hosp. 7: 112-114, 1896. 

(8) Cullen, T. S.: Surg., Gj-nce. & Obst. 22: 258-260, 1916. (9) Damhrin and 

Bernardbeiff : Bull. Soc. d’obst. et do gynec. 10: 781, 1921. (10) Di Fazio, L.: 

Arch, di ostet. e ginec. 25: 11, 78-82, 1924. (11) Bossena, G.: Atti d. Soc. lomb. 

di sc. med. e biol. 11: 179-189, 1 PL, 1922. (12) Burning, J.: GjmSc. et obst. 1: 

81-93, 1920. (13) Emanuel, B.: Ztsehr. f. Geburtsh. u. Gynak. 48: 383-427, 1903. 

(14) Estor, Grynfelit, and Aimes: Bull, et m6m. Soc. Anat. de Paris 91; 240-242, 
1921. (15) Gaeda, G.: Policlinico, sez. Pr,at. Eoma 30: 177, 1923. (16) Gumil' 

lette, B.: Bull, et mbm. Soc. Anat. de Paris 94: 494-498, 1924. (17) Guyot, et al.: 

J. de m4d. cours de Bordeaux 54: 282, 1924. (18) Eichel, P.: Bull, et mem. Soc. 

Anat. do Paris 93: 299-303, 1924. (19) Eorung, B.: Munchen. med. Wchnschr. 
71: 402, 1924. (20) Iraeta: Prensa med. Argentian, Buenos Aires 4: 200, 1917-18. 
(21) Kanthcr, 3.: Monatschr. f. Geburtsh. u. Gyniik. 83: 325-330, 1923. (22) 

Lombardi, B.: Riforma med. 40: 991-993, 1924. (23) Maecabruni, F.: Ann. di. 

ostet. e ginec. 1: 327-337, 1915. (24) Magaton, 0.: Ann. ital. di chi. 4: 495-504, 

1925. (25) Marta, A.: Riforma med. 40: 104-106, 1924. (26) Mestron, 17.; Ann. 

di ostet. e ginec. 45: 221-227, 1923. (27) Moench, G. L.: Med. Rec. N. Y. 97: 652, 
1920. (28) Moncli, G.: Deutsche med. Wchnschr. 44: 1021, 1918. (29) Orru, M.: 

Clin, ostet. 28: 550-554, 1926. (30) Saenger, M.: Arch. f. Gyniik. 21: 279, 308, 

1883. (31) Sams, L. V.; Colorado Mod. 20: 135-138, 1923. (32) Scliwars, E.; 

Bull. Woman’s Hosp. Path. No. 39-44, 1917. (33) Shaw, 77. F.: J. Obst. & Gynec. 
Brit. Emp. 32: 121, 1925. (34) Sserdjuhoff, M. G.: Arch. f. Gynak. 122: 88-101, 
1924. (35) Taussig, F. J.: Surg., Gynec. & Ohst. 19: 218-223, 1914. (36) Walther, 
C. ; Rev. mens, de Gynec., Obstet. et de pediat. Par. 14: 60-63, 1919. (37) Ward, 

77.; Am. J. Obst., N. Y. 77; 152, 1918. (38) Wells, S.: Brit. M. J. 2: 484, 1865. 
(39) Von Wincl-el, (quoted by Von Zur-Muhlen, F.) in Zentralbl. f. Gynp. 887-880, 
1910. Ein Fibromj'om des Ligamentuni rotundum uteri. (40) Vcrcesi, C.: Folia 
Gynaec., Pavia. 20; 477-500, 1924, 

817 Park Avenue. 



A CASE OP ECTOPIA CORDIS® 

Charles Lintgen, M.D., Philadelphia, Pa. 

(From the Department of Gynecology, Jefferson Medical College) 

C ONGENITAL ectopia cordis may be found ia one of several forms. The heart may 
be displaced to almost any part of the mediastinum or abdomen, or it may be en- 
tirely outside of the body. The condition has been conveniently divided into internal 
and external form depending on the location of the heart. 

Mrs. H. M., white, went into labor on the night of January 12, 1932, being admitted 
to Jefferson Hospital on the following morning. She had a pulmonary tuberculosis 
in early life, which apparently had become quiescent. No history of abnormalities, 
either on her own or the husband ’s side could be obtained. During the second month of 
pregnancy, she had attempted an abortion by means of quinine and castor oil. 

Physical examination was grossly negative. Urine and blood pressure were re- 
peatedly normal, and the Wassermann and the Kahn tests were negative. 

Labor pains were not severe, until late afternoon, when rectal examination revealed 
the head low in the pelvis, the cervix being dilated about two and a half inches. About 
10:00 P.M. the nurse reported that the patient vomited -with each pain. Upon examina- 
tion, nothing significant to account for the vomiting could be found, but it was thought 
possibly adhesions might have developed in some way between the bowel and the fundus 
of the uterus, contractions of the latter causing tugging on the bowel. The pulse, 
respirations, and temperature were normal. At 11:00 p.m. the cervix was completely 
dilated. The patient still vomited rvith the strong pains. The head, however, seemed to 
bo in the same position as it was four hours earlier. At 11:55 the head delivered 
spontaneously, but when an attempt was made to deliver the anterior shoulder, ab- 
normal resistance was felt. After it had passed under the symphysis the thorax and 
abdomen could not be delivered, beyond the umbilicus. At this time, a dark blue mass 
was noted in the region of the cord, which was manipulated through the dilated cervix. 
Beyond this mass, could be felt the taut umbilical cord, which was clamped inside the 
uterine cavity, following which the child was delivered. The placenta was expressed, 
iutact, about live minutes later, by Crede’s method, being normal in appearance and 
weighing 450 gm. The umbilical cord, however, was extremely short, measuring but 
10 cm. The cervix and perineum were lacerated. Tlie mother’s convalescence was 
uneventful, and she was discharged from the hospital on the fourteenth day after 
deliver}'. 

Upon delivery, the child cried, breathed promptly and normally, and the skin was 
pink in color. Upon the anterior chest wall, in the midline above the epigastrium, was 
a bluish, pulsating mass about the size of a lemon, readily recognized as the heart, 
protruding through an opening in the anterior chest waU due to the absence of the 
gladiolus. The manubrium sterni and the ensiform process were present. Further 
examination disclosed a craniorachischisis, a club foot (left), bilateral cleft palate 
facial hemiatrophy. The child weighed 3 kg. and was 51 cm. in length, appeared active 
and took several bottle feedings. The heart stopped beating at one time, the injection 
of a few drops of adrenalin into the muscle causing it to again beat vigorously. Death 
occurred in twenty-eight and a half hours. 

Motion pictures, x-rays, and electrocardiographic studies were made. The latter, 
reported by Dr. Boss V. Patterson, showed a pulse rate of 150 per minute, with some 

♦Read at a lueeUng of the Obstetrical Society of Philadelphia, Jlay 5, 1932. 

449 



450 


AMERICAN JOURNAL. OF OBSTETRICS AND GYNECOLOGY 


slight variation in the rhythm, possibly duo to sinus origin. Because of the altered posi- 
tion of the heart, it was impossible to compare it with the ordinary electrocardiogram. 

Many cases of ectopia cordis, where the heart was outside the body have been re- 
ported by various writers. In a complete review of all the literature, forty-eight 
distinct cases were found recorded. Space will not permit the citation of all these 
cases, but the entire bibliography has been retained by the author. Most of these 
eases are more or less similar to the one here described. In three instances, attempts 
were made to replace the heart into the mediastinum without success. In the majority 
of instances reported, the child was either born dead, or died soon after birth. 



The etiology of the condition is rather obscure, but the consensus of opinion of 
various autliorities seems to be that arrested development at a certain period induced 
primarily by a pathologic o^’um is responsible. 

In the case here described, the mother took an abortifacient drug in the early weeks 
of pregnancy. In cases of threatened abortion, where the ovum has become blighted, 
abnormalities and monstrosities occur most frequently. We might, therefore, assume 
that the development of the embryo, by virtue of possible blighting of the ovum, was 
arrested at a critical period, manifesting itself at full term bj' the abnormality 
found. 






INSTRUMENT FACILITATING ATRAUMATIC PALPEBRAL 
SEPARATION IN THE NEWBORN 

IS'Llrio a. Castallo, M.D., Providence, R. I. 

T he difficulty sometimes encountered and the trauma produced in attempting 
to place ‘ ‘ drops ’ ’ in the eyes of newborn infants has prompted this instrument. 
The procedure of a doctor or nurse struggling to open the eyes of the newborn in- 
fant with gauze aird cajoiing, or cautiously standing by to catch the baby unawares 



Pig. I. 



Pig. 2. 


and then dropping the argyrol or silver nitrate solution into the eyes has always 
been a most irritating procedure. In addition, many swollen eyelids occur, not to 
mention the trauma imparted which is at times the starting point for erythema, 
pustules and other complications. 

The eyelid separator presented is easy to operate and to sterilize properly. The 
ends of the dilators are so fashioned that one cannot, if care is exercised, get the 
instrument below the eyelids and injure the orbit. The ends of the dilators are 
inserted under the lids to either side of the palpebral fissure, and with a minimum 
of pressure the eyelids are opened and arc held in that position for as long as the 
operator desires for the instillation of the medic.ation (Fig. 2). 

The instrument has been used ivith much success and with a minimum of trauma 
to the eyelids and has been a most welcome addition to the delivery table set-up. 

Kote: The instrument is manufactured by the Fred Ilaslam Co., Brooklyn, N. T. 

255 Thayer Street. 


451 





Society Transactions 


OBSTETRICAL SOCIETY OP PHILADELPHIA 

MEETING OF MAY 5, 19S2. 

Tlie follo'n'ing papers were presented: 

A Case of Ectopia Cordis. Dr. C. Lintgen, Pliiladelphia, Pa. (See page 449.) 

A Survey of Cesarean Sections Performed in Philadelphia During 1931. Dr. C. B. 
Lull, Philadelphia, Pa. (See page 426.) 

Lesions of the Placental Vessels: Their Relationship to the Pathology of the 
Placenta; Their Effect Upon Petal Morbidity. Dr. T. L. Montgomery, Philadelphia, 
Pa. (See page 320.) 


NEW YORK OBSTETRICAL SOCIETY 

MEETING OF MAY 10, 1932. 

Dr. Harry Aranow presented a paper (by invitation) entitled An Account of a 
Tear’s Service in Obstetrics at the Morrisania Hospital: A Public Institution. (For 
original article see page 420.) 

Dr. W. H. Carj^ presented a paper entitled A Clinical Study of 100 Cases of De- 
velopmental and Punctional Deficiencies in the Female With Analysis of Treatment 
and Results. (For original article see page 335.) 

Dr. Alfred Plant read a paper (by invitation) entitled Ovarian Struma: A Mor- 
phologic, Pharmacologic, and Biologic Examination. (For original article see page 
351.) 


452 



Department of Book Reviews 

Conducted by Egbert T. Frank, M.D., New York 


REVIEW OF NEW BOOKS 


ENDOCBINOLOGT 


The four volumes on endocrinology reviewed are interesting from the different 
aspects from which they regard the subject. 

Eowe has concentrated on a large number of mainly chemical tests performed on a 
huge human material which he has, upon purely clinical grounds, divided into ar- 
bitrary groups. Mazer and Goldstein, on the other hand, have focused their attention 
mainly upon the biologic hormonal tests so far available and have limited their dis- 
cussion to the female. Engelbach ’s volumes on the other hand, in an uncritical fashion, 
emphasize the clinical phases of the subject, and focus his attention to the anthropom- 
etry, x-ray, and the somewhat doubtful adrenal and pituitrin reactions. The contribu- 
tion from Hirsch’s EandVuch is a strictly objective presentation based on morpho- 
logic studies. 

To judicious readers these books will prove of use, if sufdcient eclecticism is exer- 
cised in sifting hypothesis and conjecture from actually ascertained facts. 


The Differential Diagnosis of Endocrine Disorders f by Allan Winter Eowe, is a 
description of the “vital function tests “ which he and his group employ in order to 
discover individual departure from the normal. The description of history taking, the 
careful physical examinations and laboratory examinations performed on some 5000 
patients would be of inestimable value if I were not obliged to consider the classifica- 
tion into pituitary, thyroid, gonadal, adrenal, and pancreatic groups to be so arbitrary 
as to rob the statistics of their value. 

This does not signify that the physician or even the specialist in endocrinology 
cannot find much of interest and profit in studying the book, as the investigations are 
systematic and the clinical methods employed excellent. B. T. Franh 


Mazer and Goldstein’s Clinical Endocrinology of the Female describes the func- 
tional phases of the human female, puberty, menstruation, pregnancy, lactation, and 
the menopause. Most emphasized in this volume are the various hormonal tests, in- 
cluding the pregnancy test of Aschheim and Zondek, as well as Friedman’s, the female 
sex hormone tests in the nonpregnant female, the prepituitary hormone tests in the 
blood and urine. The general medical reader as well as the specialist and laboratory 
worker will find in this volume a very satisfactory, clearcut, well arranged and well 
balanced description of what we know about female sex physiology, both from the 
laboratory and clinical standpoint, including the most recent discoveries in this field. 
Even those not f.amiliar with the subject can orient themselves with readiness and profit.' 
A tremendous amount of material has been incorporated in this book, with readily 


By Allan Winter Rowe. 


rri DlncnoslK of Rndocrine DlKordcrs. 

The Williams & Wilkins Co., Baltimore, 1932. 

T.. "f the Pcninle. Bv Charles Ifavet- -.n.? T ^ . 

Illustrated. W. B. Saunders Co.. PhiladelpiriaTlSS^: Leopold Goldstein. 

453 





454 


A5IERICAN JOURNAL OF OBSTETRICS AND Gl'NECOLOGY 


accessible literature of G49 numbers. The authors are too optimistic as to the results 
and effects of therapy but in the main have shomi commendable reserve. The volume 
is highly recommended to an 3 ' one rvho desires to inform himself upon this important 
phase of medicine as well as to workers who can use it for reference. 

— Robert T. Fraiik 

Endocrine Medicine^ by William Engelbach, consists of three volumes and an index 
volume, the latter not having as yet been received. The author announces that in the 
volumes so far published, the suprarenal medulla, the pancreas, and the liver have not 
been dealt with and have been reserved for a later volume. According to the author, 
full}' 8 to 10 per cent of all patients have some endocrine disorder. 

Volume I covers the fundamentals among which he includes the historj’ of endoe- 
rinologj', organologj' (comparative anatomj-, embryology, and histology), to which 
onl}’ 38 pages are devoted. Physiologj- including endocrine function, animal experi- 
ments, description of hormones, and the .autonomic nervous system, are then taken up. 
Among the etiologic factors, hereditj’, incidence, age, duration, race, and sex are in- 
cluded. Such extraneous factors as food deficiencj', toxemias, emotionalism, the process 
of reproduction, tumors, and trauma may be of moment. 

The diagnostic procedures emphasize anthropometry. Such subjects as the historj-, 
the examination and illustrative case reports arc then described. Three short chapters 
deal with basal metabolism, the hormone and the specific reactions, and blood chemis- 
trj*. The concluding chapters of this volume describe the relation of endocrinopathies 
to general medicine and their relation to public health. 

Volume n deals with infantile and juvenile endocrine diseases, and Volume III 
with adolescent and adult troubles. This dh-ision may be of some utility but it entails 
endless repetitions in the text, in charts, and illustrations of bone roentgenograms. The 
text does not lend itself to detailed review. The division in Volume II under infantile 
disturbances, with minor changes is found in the succeeding subdivisions. It covers 
thyroid, hj-pophysis, biglandular (thj-roid-pituitary), gonadal disturbances (agonad- 
ism, cryptorchism, hermaphroditism), as well as the parathj-roid diseases, and again 
takes up the relation of these to general practice and specialism, as well as to public 
health. 

The practical and theoretical considerations are fullj' illuminated by a large number 
of carefullj- worked out case histories. In these it is apparent that the following are 
speciallj- stressed — the anthropometric measurements, the basal metabolism, the re- 
sponse to the adrenalin and pituitrin tests, as well as x-rays of the skull and of the 
extremities. 

The author has assembled a large number of instructive tables and charts dealing 
with measurements and statistics. 

The reviewer has found tliis book difficult to read as the arrangement of the litera- 
ture which has been studied exhaustivelj- and with great care, is somewhat involved. 
He has also found that the generalizations are ponderous and difficult to understand. 
Needless to emphasize, in a book of this size and dealing with the subject still in the 
state of flux, differences of opinion and interpretation will naturallj- arise. However, 
many will eertainlj- disagree mth the author’s conclusions, Volume II, page 94, that 
the direct treatment of pituitary disorders of this earlj- age (speaking of juvenile con- 
ditions) is also comparativelj- simple and satisfactorj-. The growth hormone can be 
supplied hy giving desiccated anterior lobe orally- or by injection and its extracts 
intramuscularly. In my opinion the reason for this apparently ready response to 
therapy is to be found in the fact that many of these disorders are temporary and self- 

^Endocrine Medicine. By l^’illiam Engelbach, M.U., F.A.C.P., B.S., M.S,, B.Sc. 
With a Foreword by Lewellys F. Barker. Three volumes and an index volume. 
Charles C. Thomas, Springfield, Illinois, 1932. 



BOOK REVIEWS 


455 


limited. This applies as well to the ‘ ‘ thyro-pituitary ’ ’ group, if such classification is 
to be used. On the other hand (page 383) Engelbach, in none of 53 cases of hyper- 
gonadism in juveniles, found any response to therapy. These cases were only in males. 
Again the author, third volume, page 200, claims that the available prepituitary prep- 
arations contain much of growth and comparatively little of sex hormone. This is quite 
contrary to my own experience. 

The illustrations are numerous (933 in number), well executed, and judiciously 
chosen from many sources to whom due credit has been given. The typography and 
format are faultless. 

Since this review was written Dr. Engelbach has died of heart disease. 

— Roiert T. Frank 


The 6th installment of the first volume of Hirsch’s Handbuch der inneren Sekretion* 
contains valuable contributions on the hypophysis and a short article on the epiphysis. 
Benda of Berlin discusses the anatomy, topography and histology of the gland. His 
contribution is brief but accurate and careful. The article on the pineal is likewise a 
contribution from the same author who has meanwhile died. 

Berblinger of Jena likewise has two contributions. The first one deals with the 
pathology and the pathologic morphology of the human hypophysis. He takes up the 
changes observed especially when there are disturbances of function of the gonads, 
thyroid, and adrenals. The normal constitution of the hypophysis is chromophobes 
52 per cent, acidophils 37 per cent, basophils 11 per cent, but with considerable vari- 
ations above and below these limits. In castrates there is a great increase of eosino- 
phils. In pregnancy and athyriosis there is an increase in the chief cells. Adrenal in- 
sufficiency appears to cause a diminution in basophils, while in diabetes melUtus the 
eosinophils are decreased. Furthermore, in two-thirds of the real nephritics, the baso- 
phils are increased. This discussion is extremely careful with good illustrations and 
a thorough inclusion of the European literature. 

Among the diseases, acromegaly, pituitary gigantism, Simmond’s disease (ascrib- 
able mainly to inflammatory causes) as well as nanism are taken up. The complex de- 
scribed by Brugsch as “acromierie” and also known as dystrophia osteogenitalis, is 
gone into in considerable detail, the symptoms being loss of hair, thirst, headaches, 
amenorrhea, and acrocyanosis of the fingers. Among other diseases described are 
dystrophia adiposogenitalis of Froehlich, acromegaly, and pituitary tumors. The 
question of the importance of the hypophysis in diabetes insipidus is discussed and 
left open. — Robert T. Frank 

OBSTETRICS 

In the Practical Medicine Series,'’ obstetrics, as before, is edited by DeLee and 
gynecology by Greenhill. As usual the volume contains careful abstracts of innumer- 
able and important articles. They are suited to every taste. Both the general prac- 
titioner and obstetrician and gynecologist can find articles that he maj' have overlooked 
in the study of the year 's literature. The value of this publication lies particularly in 
being able to see important groups of cases and important subjects assembled. Such 
individual facts as pregnancy at advanced age, pregnancy tests in normal pregnancy 
and in chorionepithelioma, the effects of th 3 miophysin may be mentioned. DeLee is 
strongly opposed to the use of pituitrin during labor. The many articles on cesarean 
section are accompanied by a warning of the extreme dangers of this operation as 
shown by the statistics gathered in the United States. Among the other obstetric sub- 
jects, the puorpcrium and puerperal sepsis are featured. 


T . Inneren SoUrctloii. Herauseepeben von Dr. Max Hirsch. 1. Band 

Lletcrunp C. Curt Kabitzsch, Deipzip, 1932. 

oditoa Obstetrics edited by Joseph E. DeLee. Gynccolopj- 

edited b> J. P. Greenhill. Series 1931. Year Book Publishers, Inc., Chicapo, 1932. 



456 


A:\IEniCAIs JOURNAL OP OBSTETRICS AND QyNECOLOGY 


In the gynecologic section, sterility is discussed, with the many tests now prac- 
ticed to determine its mechanical basis. Operations for the correction of uterine po- 
sition, still play a role. The operations for birth injuries are reviewed. Considerable 
space is devoted to the physiology of menstruation and its disorders. Some space is 
devoted to the glands of internal secretion. Tumors of the genital tract, electro and 
radiotherapy conclude this valuable volume. Robert T. Franh 

The book is one of the “recent advances’” series, and to a very great e.xtent justi- 
fies its title. It is written in a clear and concise style, easily and quickly readable. The 
obstetric division is well handled and for this alone it should be exceedingly useful. 
The statistics on maternal mortality in England are presented, and the methods ad- 
vanced for their improvement are praiseworthy. There is also a relatively e.vtensive 
chapter on the causes of fetal deaths both neo- and postnatal, well ivorth reading, as 
well as one equally ns good on the recent advances in the chemistry of the parturient. 
Antepartum hemorrhage, tho toxemias, cesarean section and puerperal infection are 
simpl}' and sanel^' discussed. Statistics wlicrever available are given to support modern 
views. As can bo readily seen there is overwhelming emphasis on prophylaxis in 
obstetrics. 

The gynecologic division of tho book docs not receive as adequate treatment. The 
methods used in the thcrapj- of cancer of the cervix, of which there has been consider- 
able recent discussion, are statistically compared. The importance of tubal insufflation 
in the handling of the sterile woman is shown and several ti’pes of plastic operations on 
the tube are described. Sampson ’s work on endomotrioma and Shaw’s on ‘ ‘ metropathia 
hemorrhagica” arc extensively gone into. Two somewhat overenthnsiastic chapters 
on physiotherapy and the use of x-rays in gynecology written by Wilson and Gage 
respectively are appended. The description of the sex hormones is adequate. 

As has been said this book is valuable. For those who prefer not to consult the 
literature it should prove to bo a welcome addition to tho library. 

— Franh Spielman 


The author discusses in the first part of this small monograph’ the collective opinions 
of previous investigators regarding the regnlatory mechanism of the acid base balance 
in pregnancy. He expresses the view that these presentations have led to the idea 
that a pregnancy acidosis can be demonstrated as a physiologic appearance, conse- 
quent upon an increase of the weak fixed acids in the blood, and that during pregnancy 
a series of regulatory influences arise to compensate for this increase. 

In the second part of the monograph he describes his theories regarding the cause of 
the phj'siologic pregnancy acidosis and of his examinations regarding the disturb- 
ances in the acid base balance in the toxemias of pregnancy. In his research he has 
used an electrometric titration of the. weak acids in a serum filtrate. Although pre- 
viously used in biology this is the first time that the method has been used to establish, 
in a direct quantitative manner, the weak fixed acids of the blood in an investigation 
of the question of pregnancy acidosis. 

He concludes that a change in the function of the glands of internal secretion, a 
hyperfunction, apparently is responsible for the physiologic acidosis of pregnancy. 
This theory he feels is supported through investigation of the blood in exophthalmic 
goiter. 

In hj-peremesis gravidarum a moderate increase in the amount of fixed acid in the 


“Recent Advnnce.s in OUstctrics and Gynecolo^. piJimdlinhra^ 

Leslie H. WUliams. 1932, 418 pages. P. Blakiston s Son & Co., Philadelpnia, 

Pennsylva^^^^o„ sUnre-Bnsen HansUnltes in Sclorangerscnnft^^^^ 

StOrunKcn Uel den Scli-iv.anKcrscliaftstoxiUoscn. von “®Akrdeinie in 

Privatdozent fur Geburtshilfe und GynAkologie an der Medjzinischen Akademie 
Dusseldorf. Seite 75, Mit 11 Abbildungen. Berlin, S. Kargrer, 



BOOK REVIEWS 


457 


blood is present. In all the cases of nephropathies of pregnancy -which the author in- 
vestigated he found a tendency to-ward a lo-wering of the acid content of the blood. 
In eclampsia, in a great majority of eases, there -was only a moderate increase in the 
fixed acids of the blood, except in the fatal cases -where at times higher amounts -were 
reached. There appeared to be no relationship bet-ween the degree of blood chemistry 
alterations and the severity of the clinical symptoms. — FMlip F. Williams 

Olin has described, Studien iiber die Ver'dnderwngen der Nacligehurt tei Lues,^ the 
changes in the placenta noted in syphilis. He bases his material on 39 cases. The 
monograph appears as a reprint from the Arbeiten aus dem Pathologischen Institut der 
Universitat Helsingfors (Finland). It is adequately illustrated by microphotographs. 

The main conclusion arrived at is that the average -weight of the placenta in eases 
of lues in -which the child is born at term, sho-ws no increase and consequently the -weight 
of the placenta cannot be considered of diagnostic value. In the placenta there are no 
pathognomonic histologic criteria except the finding of the spirochetes. It is true that 
in syphilitic placentae certain changes -which are rare in normal cases, occur -with 
greater frequency but ate not distinctive of syphilis. These include granulocytic in- 
filtrations in the decidua basalis, the typical villous hyperplasia, in a form resembling 
miliary abscesses as -well as obliteration of the villous vessels. The vessels of the cord 
frequently sho-w granulocytic infiltrations in their -walls or in Wharton’s jelly. These 
changes, -while suspicious of syphilis, do not assure the diagnosis. It is difficult to find 
spirochetes in the placenta, resembling their infrequent presence in gummatous lesions. 
Antisyphilitic treatment given during pregnancy appears to inhibit the formation 
of these histologic changes to a great degree. 

This monograph -with its large bibliography should prove of value. 

— JR. T. Franh 


Hussy’s book. Her gchurtsMlflich-gynaehologisclie Sachverstandigc,'‘ dealing -with 
the obstetrician and gj-neeologist as an expert -witness, treats mainly of the aspects of 
the Swiss law. It covers the important questions which arise, including the diagnosis 
of pregnancy and puerperium, virginity, puberty, duration of pregnancy, criminal 
abortion, infanticide. In the gj-necologie section, abortion and trauma, and the ef- 
fect of trauma or accident upon the changes in position of the uterus are dealt -with. 
In an appendix the legal indications for induction of abortion, the questions arising 
from the duties of physician toward his patient, versus those toward the community, 
etc., are taken up. — Foiert T. Frank 


This is a large work, Traiado do Ohstetricia,'” covering most of the obstetric field. 
It begins -with a laudable short history of the development of this branch of medicine 
before taking up the subject proper. Most of the material is well handled and fully 
described, although the arrangement of the chapters shows some lack of coordination. 
Pathology is stressed throughout the book, but it is hard to understand how a work of 
this magnitude can have omitted a clear and comprehensive chapter on prenatal care. 
Also, as this is the sixth edition, more careful revision might have brought the book 
up to date. As examples there may be cited the omission of the important work of 
Corner in the chapter on physiology, which would have eliminated much of the discus- 
sion on the relationship between tho corpus luteum and the fertilized ovum; and in 
the chapter on pregnancy tests, the omission of the Friedman test rvith the inclusion 
of numerous obsolete tests. The work also could well do rvithoiit such therapy as the 


’Stndlcii lllicr «nc VcrlliKlcrunKcii clcr XncliKoliurt liel B-uck. Von T E Olin At:, 
sistent der dormatoloBlschcn Klinik in Helsinprfors. Gustav Fischer, Jen.a J 931 
'Der FcInirtHliilflicli-fo-nnckoIopriKcIic SnelivcrutlijidiKc. von Dr! Paiil Hiis<;v 
Priv.atdozent, Hans Huher, Bern -Berlin. 1931. ‘ HUssj, 

’'Trntndo do ObHtetrieIn (SpnniHli). By Sebastian Recasens. Sixth edition •> 
volumes. Salvat Editore.s, Barcelona, Spain. ' ‘ “ 



458 


AJIERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGV 


use Of drugs on a "similia simiUbus eurantur»' basis. Some mention of the fact that 
tlie Sclmltze and Byrd methods of resuscitation of the newborn are undesirable might 
have been made. 

On the other hand, such chapters as those on obstetric anesthesia, monstrosities, de- 
formities of tlie pelvis and the operative field are worthy of praise. The chapter on 
monstrosities is especially tliorough. The author has used pernocton as an anesthetic 
and has improved liis results Ijy combining it with luminal. 

On the whole, as a text and reference book, the work should be extremely useful. 
Jluch material may be found in it not usually included in the average textbook. The 
illustrations are adequate. —Franh Spiehnan 

Liepmann and Danclius in this beautiful otlo.'s” of roentgenograms present their 
views regarding the mechanics of birth and collateral subjects as disclosed by radiog- 
raphy. Following a brief historical sketch of the subject they discuss the technic which 
they use in the Frauenklinik "Cccilienhaus,'' the normal position and attitude of the 
fetus in pregnancy, the changes caused by such factors as the size, the position of the 
woman, and the muscle tone of the uterus. Anomalies of fetal position and presenta- 
tion in pregnancy and in labor and their spontaneous correction during birth are shown 
in serial roentgenograms. 

The authors consider the most important use of roentgenograms in obstetrics to be 
tho demonstration of pelvic deformities and the roentgenologic measuring of such 
pelves. The axial method of Ifartius, the lateral method of Guthman and the stereo- 
scopic method are described and discussed at length. The technic, the advantages, and 
the limitations of all three are given. Liepmann advises that every obstetric clinic, 
with a large amount of material, should have an easily available roentgenologic de- 
partment and that many more cases should be subjected to this type of study than 
heretofore. In the Frauenklinik “ Cccilicnhaus ” all tliree methods are in common 
use and from a combination of the findings an exact knowledge of the obstetric situation 
present is easily obtained. 

Many of tho common errors in the estimation of pelvic capacitj' are explained and 
formulae are given for geometrically ascertaining various measurements. Fetal ab- 
normalities and signs of fetal deaths as portrayed by the roentgenograms are discussed 
in detail. The mechanism of birth as shown by the roentgenograms supports the 
theory of Sellheim, to w'hom, it may be mentioned, this book has been dedicated on his 
sixtieth birthday. The various mechanisms of the third stage of labor have been shown 
bj' injecting the vessels of the cord, immediately after the severance of the child, with 
an opaque medium. 

With the subject handled largely from the practical standpoint, this monograph with 
its profusion of roentgenograms should make a special appeal to obstetricians. 

— Philip F. Williams 


The increasing interest in maternal welfare in the past two decades is manifest in 
the number of publications which have appeared on prenatal care. It has remained 
for Dr. Irving to strike a happy medium between the insurance company or govern- 
ment pamphlet and the miniature textbook on obstetrics, and to give ns a satisfactory 
EandhooF for the Expectant Mother.^ 

Here the fundamental facts of reproduction are presented in an easily understand- 


“Gebnrtslielfcr und KontRcnblld, Eiwvelterune und 
durcli die Ronfgendiagnostik. von Univ. Professor Dr 
des Deutschen Instituts fiir Frauenkunde und 

Berlin, und Dr. Gerhard Danellus, Assistenzarzt f.ld Srhwarzinberg 

haus.” Seite 262; 160 Abbildungen. Berlin und Wien, Urban und Schn arzenberg. 

Expectant brother's Handbook. ®y,f.'’?f.®*l‘=S£Ve?HSan'*‘Bosto^ 
sor of Obstetrics, Harvard Medical School. Obstetrician, Boston 

Hospital. Pp 200 ; 26 Illustrations. Houghton Mifflin Companj, Boston 
York, 1932. 



BOOK REVIEWS 


459 


able form and oft repeated superstitions dispelled. The rules for prenatal hygiene 
are clear and simple and thoroughly explained. The woman is plainly told the cause 
of some pathologic conditions and the significance of warning symptoms of approaching 
danger. The process of childbirth is made clear to the intelligent woman wthout 
creating any fear or mystery about it. The average woman will be glad to read a dis- 
cussion on obstetric analgesia and anesthesia which the lay writer so often luridly por- 
trays for her. The chapters on the puerperal period and on the newborn are excellent. 

This book may be highly recommended with the feeling that the reading of it by a 
pregnant woman will make her a more cooperative and understanding patient. 

— Philip F. Williams 


GYNECOLOGY 

The author has the fortunate qualification in writing this book, Pliysilcalisclie Ther- 
apie der FrauerCkrankheiten^^ in that he has been engaged not only clinically in gyne- 
cology and obstetrics but also personally active in roentgenology at the same time. In 
the opening chapter on the influence of radium and roentgen rays upon the body the 
author is of the opinion that the deleterious effect on pregnancies subsequent to the 
raying is exaggerated. The psychic and vasomotor symptoms of the artificial meno- 
pause he states are five times as frequent in women under forty years of age castrated 
by the roentgen ray as compared with those undergoing bilateral oophorectomy at 
operation. 

The direct and indirect effect of artificial light therapy in various gynecologic con- 
ditions includes mention of the markedly beneficial effect of such therapy upon pre- 
eclampsia. The various methods air, water, light and electrical conduction of apply- 
ing heat in gynecologic conditions are presented. The author, seemingly, is not 
convinced that the gonococcus can be killed by diathermy in the human body through 
elevation of the temperature to a lethal degree for bacteria. Nor does the author 
feel that massage and electrotherapy, galvanic or faradic, offer much aid. 

In the second part of the book particular gynecologic conditions are considered one 
by one with full consideration of the help one may expect from physical methods, and 
with much attention to detail in technic and dosage. Of particular interest is the dis- 
cussion of cervical carcinoma. In Budapest operability is low, and operation is reserved 
for those eases suitable for vaginal hysterectomy (Schauta) . The abdominal route is 
exceptionally used and only for cases complicated by pregnancy or other conditions. 
Pre- and postoperative deep roentgen rajflng is customary in the operable cases. In the 
nonoperable cases massive doses of radium are never used, reliance being placed upon 
the supplementary effect of roentgen therapy to a moderate dose of radium. 

In an equally comprehensive consideration of myoma the author refers to the in- 
creasing number of such tumors treated by radiation, with a declining indication for 
operation. The applicability of roentgen ray to pituitary, spleen, thjToid and ovarian 
exposure, in amenorrhea, sterility and disorders of menstruation is sharply limited. 
Inflammations of the pelvic organs present, according to the author, a wide field for 
the use of physical methods. In the clinic at Budapest, from which the book emanates, 
a most conservative attitude is held, even to the point of temporary castration, by the 
roentgen ray in adnexal disease, to give a prolonged rest period from cyclical actinties. 

The final chapters describe the technic of the physical methods previouslj- discussed 
with dosage tables for radium, formula for superficial and deep roentgen ray therapy, 
and light and diathermy machines. 


"PIiyslknllKelic Thernpto der Frnncnkrnnkhclten. Ivurzcs Eehrbuch fUr nrak 
Uscho Arzto mit besondorer Beriicksichtlpunp der Indlkationen Von Privatdozent 
Dr. Felix Gill, Belter dor Strahlcn.abtcllunfr der II. Universitkts-Frauenklinlk In 
Budapest, Mit elnein Vorwort von Prof. Dr. Stephen v. T6tli, Dlrektor der 11 Unl- 
yersltiits-Frnuenklinik in Budapest. Selten 234; MU G7 zum Tell farbicren Ab- 
blldungen. Berlin and V'ien, Urban und Schwarzenberpr, 1P32. ^ ” 



460 


AJIERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


This exposition o£ the uses of physical methods in gynecologj' is so C 0 D]p]ete in both 
the cUnical and technical aspects of the subject that it should be extremely useful not 
only to the gynecologist, but also to the roentgenologist and physiotherapist. 

— Philip F. Williams 

This compact Synopsis of Gynecology^'- is a miniature textbook. Here the medical 
student will find a very concise and definite presentation of the subject. The con- 
sideration of the general principles, including treatment, is so compreliensive that the 
book will be quite satisfactory to a large group of the profession who do not specialize 
in gynecology yet need a working guide for the proper care of their patients. 

— Philip F. Williams 


Daniel’s monograph on GeJiital Inhcrculosis in WomeiW appears as one of the mono- 
graplis edited by Sergent, Mignot and Turpin in their series, “La Pratique Medicale 
Illustree. ’’ It gives a thorough insight into all forms of genital tuberculosis. His 
personal material consists of 155 abdominal cases in which genital tuberculosis was 
noted in 5. The monograph contains nothing new but is thorougii, well -vvritten and 
well illustrated, mainly with illustrations obtained from standard sources. Among the 
laboratory tests for determining the presence of tuberculosis, Calmette ’s ophthalmo re- 
action is mentioned. The author emphasizes that the rare cases of postmenopausal 
tuberculosis give symptoms, especially uterine bleeding, resembling that seen in fundal 
carcinoma. Daniel advocates operation in the majority of cases in preference to the 
nonoperative modes of treatment. — P. T. Fraiih 


Moulonguet, in the second part of the Female Genital Traci'* begins with func- 
tional conditions of the ovary and uterus which he calls “dystrophies.” His subdi- 
vision of follicular cysts, based on the hormone contents, is worth emphasizing. 

The author then takes up benign and malignant uterine neoplasms. His description 
of fibroids is detailed and clear. In a short discussion of the treatment, no mention of 
the fibroids requiring no intervention is made. Under malignant cervical lesions some 
extremely interesting adenomata and leucoplakia of the cervix are described. The 
description of sarcoma of the uterus is somewhat short. 

A number of interesting cases of fallopian carcinomata are given. An excellent 
series of chapters on tumors of the ovary and broad ligament then follow. Pseudomucin 
cysts are called ‘ ‘ enteroid ’ ’ because of their enzyme contents of invertin which the 
author says is strictly limited to entodermal tissues (intestinal tract). Such rare 
conditions as ovarian seminoma and folliculoma are fully described on the basis of an 
apparently large material (8 f olliculomata) . Considerable space is likewise devoted 


to endometriosis. 

This book will prove of great interest to gynecologists and pathologists, particularly 
because of the large number of excellent illustrations of rare conditions. Operative 
technic is not discussed in this survey. A real lack will be found in the fact that no 
statistics of the frequency of occurrence of any of the conditions described has been 


Roberts’ short monograph on Prolapse of the Female Pelvic Viscera'’' has as its 
basic theme a careful dissection of the cellular tissues of the female pelvis situated 


"Srnovsls of Grticcolosr. By Harry Sturgeon Grossen, 
sor of Clinical Gynecology, Washington University Medical School, and Gynecolo 
gist in Chief to tL Barnes Hospital, and Robert Crossen M.D.. 

Clinical Gynecology and Obstetrics, Washington University School of Medicine. 
Pp. 220; 110 Illustrations. The C. Y. Mosby Company. St. L^is, 1932 

Tubercnlose GCmlfale de la Femme. Par Constantin Daniel. G. Doin Cie, 

-fles Dmgn„..ties Anntomo-CUninues de P. Uece.ie A,, i-arcll Genital de la Femme 
(Seconde Partie). Par P. Moulonguet. Masson & Cie, Pans ryj.:. ^ 

^Recent Work on Ptosis (Prolapse) of the Female Fell ic Viscera. l 
heth Roberts. Dickson and Scudamore, London, 1931. 



BOOK REVIEWS' 


461 


above the levator diaphragm and those portions anteriorly which support the hiatus left 
by the levator. The structures in question have been renamed by the author, the ‘ ‘ meso- 
vesico-miillerian suspensory tissues ’ ’ or the ‘ ‘ myo-fibro-mesial tissues. ” In an appendix 
some instructive roentgenographs with the barium filled bladder, are given in the prone 
and standing posture. It appears that the author's description of the “suspension 
support” in the region of the supravaginal cervix and fornices does not differ greatly 
from that of all recent investigators. — Robert T. Franh 

A committee of the American Gynecological Society has prepared A Syllabus of 
Lectures on Gynecology for Aurses” which is a companion volume to a similar syllabus 
on obstetrics issued some years ago. The framework of the nine lectures into which the 
material is divided permits for easy expansion or necessary alterations to meet local 
needs by the instructors. It also lends itself to supplementary teaching by lantern 
slides or blackboard illustrations. The text is sufficiently complete to be utilized as a 
textbook by the nurse in training. Sponsored bj' sueh an authoritative group the 
syllabus merits wide adoption. — Philip F. Williams 

MISCELLANEOUS 

Cannon’s book, The Wisdom of the Bodyf° is designed for the general reader, but 
the medical man and biologist will find much of interest in its pages. Tlie title used by 
Cannon was adapted from the title of one of Starling ’s orations. Cannon emphasizes 
the word “homeostasis” as a condition which may vary, but which is relatively con- 
stant. In the main, the subject matter is based on researches coming from the Harvard 
group but naturally the world’s literature is likewise utilized. 

Homeostasis of blood sugar, blood proteins, blood fat, and blood calcium, as well 
as neutrality of the blood are some of the main topics. The role of the sympathico- 
adrenal system in maintaining balance, is somewhat overemphasized. This book gives 
an excellent survey of modern viewpoints of the physiologist, admirably expressed, so 
that any educated person should be able to grasp its contents without difficulty. 

— Robert T. Franh 


The eugenic, social and therapeutic values of human sterilization laws are treated 
exhaustively in this study. Human Sterilisation.-'^ The author’s interest in the subject 
was created by the decision of the United States Supreme Court in the Bill v. Buck 
case which upheld the Virginia human sterilization law. The present volume represents 
his researches into this recent procedure for the many cacogenic people in our midst, 
comparing the merits and demerits of segregation against human sterilization as a 
social therapeutic agent. The result of this inquiry forms a very scholarly and scien- 
tific treatise, handled without any evidence of bias or prejudice. 

It is remarkable that in the twenty -five years of the movement, legislation regarding 
human sterilization has been adopted in 27 states, but of the millions of cacogenic 
people only some 12 thousand have been subjected to legal sterilization, under the 
existing statutes, and over half of those in California. There is a comprehensive re- 
view of the relation of eugenics and social legislation. The second part of the book- 
reviews the three landmark legal decisions on human sterilization, and the present 
legal status of our human sterilization laws. 

The influence of heredity in continuing the various traits of the many types of dys- 
genic people, mental diseases, deficiencies, and the lieredit.y of ps.vchot'ic traits, is 


SytlnUns of I.ocluroK on Gyno«-olosa>- for XiirKcK. Prepared bv .a 
Appointed by ’Hie Americ.an Cynecoloprical Society, 1932. Copies mav be obtained 
from Dr. Emil Nov.alv. 2C East Pre.ston St.. Baltimore Md obtained 

YorkT'lMY'"'’""’ Cunnon. W. w. Norton & Co., New 

”irnnmn Stcrtllrntion. Tlic Hlstorj- of tJie Spxiinl 
J. H. Landman. Pb.D., J.D.. J.S.D.. Tim College or^e City 

millan Company, New York, 1932. ^ xork. The Mac- 



462 


AMERICAN journal OP OBSTETRICS AND GYNECOLOGY 


Uioroughly examined. In a critique of eugenics tlie futility of human sterilization, 
is suggested in a question as to whether the apparent mental subnormal or tlie latent 
carrier of the mental subnormality is to be sterilized. The author feels that human 
sterilization, as a social program, requires more scientific evidence in its favor. 

The surgery of human sterilization takes up the possible methods of prohibiting 
conception. With the detail characterizing the book the author discusses several bi- 
ologic methods, hormone, spermatoxin and insulin. The motivation of the movement 
is dispassionately discussed. The chapter on the administration of such laws shows 
not only the practical side of the question, but the many impracticabilities and techni- 
calities of their enforcement. 

This volume is complete and informing, well documented, and a valuable reference 
work for those whose work brmgs them into the slightest medical, social, or judicial con- 
tact with the problem of cacogcnicity. — PJiilip F. Williams 

‘ ‘ The central motive of this book^ has been simply to give to the reader a sufficient 
background of knowledge to encourage him or her to take advantage of the services 
of physicians rather than depend upon unreliable and sometimes dangerous popular 
nostrums." The author, a layman, who has conducted a general orientation course 
for years on the subjects of sex h 3 'giene and marriage has informed himself thoroughly 
on the plij’siologic, psychologic and sociologic angles of the problems connected with 
these two subjects. 

The medical collaboration on the book has been incorporated with discernment. The 
attitude of modern society toward sex questions and moral equations reveals a full 
knowledge on the part of the author as to the broad social and economic phases of the 
topics discussed. The first nine chapters lead inevitablj' to the chapter on the need 
for birth control. Here the many arguments in support of a widespread diffusion 
among all grades of society of effective contraceptive methods are set forth most 
convincingly. 

The present legal status of the dissemination of information regarding birth control, 
here and abroad, shows tliat 25 states in our country have no laws mentioning the pre- 
vention of conception. The two final chapters list the organizations engaged or inter- 
ested in birth control, with street addresses of individual clinics, and a discussion of 
the different methods of contraception. A final reference note at the end of the book 
mentions the apparent admission of the morality of birth control in principle by the 
Eoman Catholic Church. 

The book presents many statements otherwise found scattered in books probablj’ 
not accessible to the author’s audience or students, a concise unobjectionable presenta- 
tion of sex hygiene and the marriage relation, and an able case for wide dissemination 
of contraceptive knowledge. The central motive of the book will probably be achieved. 

— Philip F. Williams 


Various plastic operations on the breast are presented in this small brochure. Pie 
Formfefiler und die Plastischen Operationen der Weibliohen Bnist." The authoi re- 
gards many cases of errors in configuration of the mammary glands as evidence of an 
underlying disease. For instance, the sagging breast is an expression of the connective 
tissue weakness seen also in other parts of the body in gastroenteroptosis, retroflexion 
or prolapsed kidney. The hyperplastic breast is regarded as an e.xpression of a general 
fat dystrophy. Asymmetry is significant at times of lung tuberculosis. To correct t le 
cosmetic errors in such deformities the author has outlined various operations suitable 
for the different conditions, describing the methods of Lotsch, Lexer, Jose^, Sellheim 
and various procedures which he himself has devised. —Flnhp F. Williams 


^TJie Hyeriene of Marringe. By 

College, Chicago. The ratloAen dcr Weihlielien Bmst. von 

Dr.“Erna*'Gmsmln""sMfe "slbhildungen. Stuttgart, Ferdinand Bnke, 1930. 



BOOK REVIEWS 


463 


This little book of Badiologic Maxima gives information in short, concise para- 
graphs. Most of the material offered is well established. There is a tendency to dwell 
on the importance of radiology to the physician rather than the radiologic field itself. 
Numerous excerpts to show its importance are quoted from the publications of authori- 
ties. Its value to the radiologist is problematical. — Frank Spiehnan 


Winter’s widely known book on the Indications and Methods of Artificial Abortion'* 
has appeared in a second edition, thoroughly revised noth the aid of Professor Naujoks. 
The first and largest part of the volume is occupied by a critical analysis of all the 
various medical indications for artificial interruption of pregnancy, beginning with a 
clear expose of the ever complex problem of the toxicoses. Opinions of many -writers 
are freely quoted but one readily notices that Winter and Naujoks themselves stress the 
greater weight of clinical conditions in the individual case over standard rules or mere 
laboratory findings. All the diseases more commonly met as complications of pregnancy 
are carefully discussed and proper emphasis placed on facts more recently revealed, 
such as recognition of fetal malformation by means of radiograms, the likelihood of 
deleterious effect upon the fetus in utero as result of heavy, therapeutic radiation un- 
wittinglj' applied in the course of pregnancy. 

Among social indications for artificial abortion the writers are vrflling to admit only : 
the necessity of heavy work, impossibility of sufficient rest, undernourishment, emo- 
tional strain and similar factors which inevitably would seriously aggravate a disease 
complicating the pregnancy. Therefore, under such conditions the obstetrician is 
morally obliged to consult an expert internist. For the authors, purely social considera- 
tions could never justify abortion, simply because the existing laws forbid it. 

Eugenistic indications, at least theoretically, would seem plausible, but actually do 
not exist for the individual case because human genetics up to now have failed to 
establish any basis for a definite prognosis in regard to the child for any specific 
instance. 

A short chapter dealing with the laws of Clmrch and State makes interesting reading. 

The volume closes rvith a discussion of the various methods of artificial termination 
of i)rcgnancy. Drugs taken by mouth always are uncertain in effect. Eoentgenisation 
of the pregnant uterus has its evident drawbacks. All intrauterine manipulations, and 
among them particularly the more recently advocated injection of salve, favor infec- 
tion. Curettage is convenient but useful only in very early pregnancy. Preliminary 
laminaria dilatation of the cernx can be rendered fairly safe by extreme care in technic. 
Forcible dilatation of the cervix -vnth instruments favors lacerations and even perfora- 
tion. The last mentioned injury certainly is more common than generally suspected. 
Digital removal of fetus and placenta after appropriate cervical dilatation is the 
safest method. The ovum is loosened and then its expulsion aided by compression of 
the uterus. Only if the presence of rests of the ovum has been definitely ascertained, 
Winter ’s abortus forceps can be employed. For far advanced pregnancy metreurysis 
or vaginal hysterotomy are recommended. For some cases an abdominal cesarean 
section must be considered. 

To those f.-imiliar -with the first edition it becomes evident that Winter in spite of the 
present prevalence of more radical views and in the face of a very active propaganda 
for liberalization of existing opinions concerning the justification of abortion, still 
maintains his rather conscrv.ative but entirely fair and sane attitude in regard to the 
right of the obstetrician to terminate a pregnancy. Hugo Ehrenfest 


127 pages. Radiological Revlc-sv 


“Ilndlologlc MnxIniN. By Harold Swanberg. 

Publishing Company, Quincy, Illinois, 1932. 

=‘Dcr KticnsHtclic Abort. .Indikntionrn iind rUrtliodon Bv Von Prof Tir 
Winter und Prof Dr. Hans Naujoks. Zwelte vollstacndig umgearbeUeie AihS 
A orlag von Ferdinand Enke, Stuttgart. 1932. ^ r Jcitete aui i.ige. 



Item 


AMEEICAN BOARD OP OBSTETRICS AND GYNECOLOGY 

The next general, clinical examination of the Board is to be held in Milwaukee on 
Tuesday, Juno 13, 1933, immediately preceding the annual session of the American 
Medical Association. Eeduced railroad rates will apply. 

The annual dinner and Bound Table Conference will be held at the Hotel Schroeder, 
7 P.M. on June 14. A short address will be made by one or more of the Board officers 
and a general discussion of Board activities will follow. All Diplomates of the Board 
are urged to attend and to bring any interested guests. The subscription for the 
dinner ■will be nominal and reservations may be made in advance through the office 
of the Secretary. 

For further information and application blanks address the Secretary, lOlo High- 
land Building, Pittsburgh, Pennsylvania. 


464 



American Journal of 
Obstetrics and Gynecology 

VoL. XXV St. Louis, May, 1933 No. 5 


Original Communications 


THE VOLUMETRIC DETERMINATION OF AMNIOTIC FLUID 

WITH CONGO RED* 

A Pkemminary Report 

WiEUAM J. Dieckimann, B.S., M.D., AND M. Edward Davis, B.S., M.D., 

Chicago, III. 

(Froin the Department of Obstetrics and Gynecology, the Josiah Macy, Jr., Foundation, 
University of Chicago and the Chicago Lying-in Hospital and Dispensary) 

T he quantitative variability of the liquor amnii is of considerable 
clinical importance. The average amount of fluid occurring in pa- 
tients at term has been determined by several investigators by collecting 
the fluid at the time of delivery. Lehn, in 1916, reported 1200 c.c. as the 
average amount of fluid in a multipara, compared with 1000 c.c. in a 
primipara. This difference is ascribed to the fact that multiparae carry 
their babies longer and, therefore, accumulate more fluid. This explana- 
tion is entirely inadequate. 

Individual variations in the amount of fluid may be very marked, and a 
quantity greater than two liters is usually considered excessive. Minor 
degrees of hydramnion are common, although marked degrees are rare. 
Kiistner has reported 15 liters and Schneider has observed 30 liters at the 
sixth month of pregnancy. A marked diminution in the amount of fluid is 
of less common occurrence. Taussig reports a case in which there was less 
than an ounce of thick, viscid fluid. It has been observed, clinically, that 
there are variations in the amount of fluid in the same patient at various 
times. A moderate poljdiydramnion has been noted gradually to disap- 
pear, so that at term there was present only the normal amount of fluid. 

We have been interested in finding a method to determine the amount of 
liquor amnii in utero without disturbing the pregnancy, so that these 
quantitative variations could be studied. Such a method would establish 

‘Read before the Chicago Gynecological Society, .Tune 17, 1932. 


Note: The Editor accepts no responsibility for the views .and statements of authors 
as published in their “Original Communications.” 

G23 


624 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


the normal amount of liquor amnii during the last trimester, would de- 
termine the rate of increase or decrease in amount, and perhaps throw light 
on the factors controlling the formation and accumulation of the fluid. The 
dye method has been used successfully in the colorimetric determination 
of the quantity of circulating blood, so we decided to apply this method 
to our studjL 

The dye method ivas introduced by Emvntree, Keith and Geraghty for 
determining plasma and blood volume. As applied to the quantitative 
measurement of the liquor amnii, it involves the introduction into the 
amniotic cavity of a nontoxic, nonabsorbable dye. The dye remains in the 
uterus long enough to be thoroughly mixed and its concentration in the 
amniotic fluid is then determined eolorimetrically bj’’ comparison with a 
suitable standard mixture of dye and fluid. We make use of Congo red be- 
cause this dye has been used extensively in work on blood volume. It may 
not be tlie best dye available, and we are at present making use of other 
nontoxic dyes to find the best suited for this work. 

METHOD OF COLLECTING FLUID 

The vaginal route was at first considered to be the best because of the 
relative safety of any procedure by this route. Culdesac puncture is 
usually a harmless procedure. With a good aseptic technic, puncture of 
the uterine eamty through the culdesac or by way of the anterior route 
underneath the bladder, likewise, is a relatively safe procedure. We at- 
tempted both of these routes, using a three inch 19 gauge flexible needle. 
In only about half the cases could we gain access to the amniotic cavity. 
The punctures usually caused considerable bleeding, particularly in the 
anterior route, and in some of the cases the liquor amnii was tinged with 
blood, making the specimens useless. Some of the cases in which we suc- 
cessfully obtained liquor amnii continued to leak fluid or were followed by 
rupture of the bag of waters. Furthermore, repeated punctures on the 
same patient were impossible because of the complications cited, plus the 
discomfort and the increased danger to the patient. W e, therefore, decided 
that the vaginal route was not feasible for our problem. 

Puncture of the uterine cavity from above was then considered. It had 
been done only rarely and was considered to be dangerous to the patient. 
The uterus closely approximates the abdominal wall during the last six or 
eight weeks of pregnane^’’ and during the entire last trimester, when the 
uterus is abnormally large because of a polyhydramnion. Unless the pa- 
tient has adhesions, due to a previous operation, there is little danger of 
injury to the intestines, when the patient is in the supine position. When 
the bladder is empty, it is usually a pelvic organ and, therefore, out of 
danger. Leakage of fluid into the abdomen was not noticed and evidently 
does not occur. Theoretically, there is a possibility of sticking the child, 
but this does not often happen and a needle prick would do damage in very 
few places on the child’s body. 



DIECKMANN AND DAVIS: AMNIOTIC FLUID 


625 


The first attempts were made on patients during cesarean section. On 
opening the peritoneal cavity, the lower uterine segment, or any other site 
on the uterus beneath which there appeared to be fluid, was punctured with 
a three inch 19 gauge needle and a sample of fluid withdrawn. The syringe 
was then disconnected and one cubic centimeter of Congo red injected. At 
varying time intervals a second sample of fluid was withdrawn through the 
same locality. The baby was moved about in the uterus to secure an even 
distribution of the dye in the liquor amnii. W e observed that there was ab- 
solutely no leakage of fluid through the needle punctures in the uterus. 
Furthermore, since it was a simple procedure, with apparently little risk to 
the patient, we concluded that abdominal puncture of the uterine cavity 
was entirely feasible in carefully selected cases. This procedure is further 
justified because it opens up an entirely new field of investigative pos- 
sibilities on the physiology and pathology of pregnancy, labor, and mem- 
brane permeability. 

The patients we selected for this procedure were in the hospital for the 
various complications of pregnancy. Many of them had toxemia. All of 
them were in their last trimester, the majority at or near term. In most of 
the cases we obtained three samples of fluid, which necessitated three punc- 
tures of the uterine cavity. The first sample was taken before the injection 
of the dye and two samples after its injection. The time interval between 
samples was noted. In several eases, puncture of the usual site yielded 
pure blood, and the needle was withdrawn. If blood was obtained on the 
opposite side of the uterus, it was concluded that the needle had entered the 
placenta, because of its unusually low attachment. Needle puncture of the 
placenta in situ would probably yield pure blood because of its extreme 
vascularity without causing any damage to its substance or attachment. 
In two instances this happened at operation and the low-lying placenta 
was found. The placenta and its site were carefully examined, but we 
failed to find a hematoma or other sign of damage. In three or four other 
instances, the patients subsequently delivered from below entirely un- 
eventfully, and the placentae were entirely negative. No puncture marks 
on the baby could be seen in any case. 

Our first patient was one near term with a moderate polyhj^dramnion 
and a floating head. After carefully preparing the slcin with iodine and 
alcohol, the skin was anesthetized with one-half per cent novoeaine. Some 
novoeaine was injected into the abdominal wall, along the line of the pro- 
posed puncture. The amniotie cavity was entered easily, a sample of fluid 
obtained, and the dye injected. Several more samples were easily obtained 
at varying time intervals, to determine the time necessary for complete 
diffusion of the dye. 

TECHNIC 

The uterine cavity can be best entered 5 to 6 cm. above the symphysis, when the pa- 
tient is on her back and the bladder completely emptied. The right or left of the mid- 
hue is chosen, depending on which side fluid is more easily palpable. Usually, it is 



626 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


easiest to gain access to the utoviue cavity on the side opposite the hack. The patient 
may suddenly jerk when the needle goes through the peritoneum. About 5 c.c. of clear 
liquor amnii are withdrawn, the syringe removed, and by moans of a tuberculin sjwinge 
1 c.c. of Congo red injected. The needle is withdrawn and a second puncture is made in 
an hour, at which time a second 5 c.c. sample of pinkish liquor amnii is aspirated. 

A 1.5 per cent solution of Congo red in water is placed in 2 c.c. ampoules, sealed and 
autoclaved. The standard consists of a 1:400 dilution of the dye. The colorimeter is 
set at 20, and the standard is diluted so that the color appro.vimates that of the un- 
known. The dilution is always in multiples of 400, that is, 1:800; 1:1200; 1:4000, etc. 
The calculations are as follows: 

20 cubic centimeters of dilution 

— = E. = cubic centimeters of amniotic fluid 

X R 

One of the problems connected with the dj’C method was the determination of the 
most satisfactoiy time after injection for the removal of the liquor amnii to determine 
the volume. One must allow adequate time for a thorough mixing of the d 3 'e with the 
fluid. There is no current in the amniotic cavit}', but the movements of the fetus aid 
diffusion. Samples of fluid were removed at various intervals and it was found that a 
thorough mix could be secured in from fifteen to sixty minutes, depending on the volume 
of fluid (sec Table II). In the circulation Smith has shown that about 12 per cent of 
the dj’e is removed the first hour. However, in the amniotic cavitj', the dj’e disappears 
verj’ slowlj’ and there is no appreciable loss in 24 hours. In two patients we removed 
samples at the end of 12 and 24 hours and the readings were alike within the limit of 
error. The dj’c will complctcl.v disappear from the liquor amnii in about a week or 10 
days. The membranes and placenta were ex.amined in two cases, after several injec- 
tions of dye into the uterus, and no evidence of the Congo red could be seen grossly or 
microscopically in the cells. The dye must be removed by the maternal circulation. 

DISCUSSION 

The colorimetric dye method used in blood vohime work is applicable for 
the quantitative determination of the liquor amnii in utei’o. Roth, in vivo 
and vitro experiments with this method, has shown that determinations 


Table I. Comparison of Volujib Calculated by Dye Method and Actually 

Measured at Delivery 


CASE NO. 

VOLUME DYE METHOD 

VOLUME OF FLUID 
COLLECTED AT DELIVERY 

52069 

413 C.C. 

400 C.C. 

56663 

1110 e.c. 

1050 C.C. 

57857 

976 c.c. 

950 C.C. 

60943 

460 c.c. 

450 c.c. 

54309 

490 C.C. 

450 c.c. 

55784 

317 C.C. 

300 c.c. 

Table II. 

Complete Diffusion of Dye Within an Hour 

Case 37855. Polyhydramnion 

11:40 A,M. 

Dye injected 

1730 c.c. 

12:40 P.M. 

First sample 

1:00 P.M. 

Second sample 

1758 c.c. 

1:20 P.M. 

Third sample 

1712 c.c. 

1:40 P.M. 

Fourth sample 

1738 c.c. 

2:00 P.M. 

Fifth sample 

1730 C.C. 


DIECKMANN AND DAVIS: AMNIOTlC ELUID 


627 


can be carried out with a maximum error of 5 per cent. In the patients in 
whom we were able to collect the liquor amnii at delivery, our results were 
well within this limit of error (see Table I) . The procedure as described 
in carefully selected cases carries with it little danger, as no untoward re- 
sults occurred in 25 cases, which serve as a basis for this preliminary re- 
port. It is, however, not without conceivable danger. 

The average amount of fluid in the majority of eases was distinctly less 
than that given by Lehn. The number of observations are too few to draw 
any conclusions at the present time. The amount of liquor amnii is not 
constant nor does it always increase with the duration of pregnancy. In 
one patient in which we were able to obtain five readings at varying inter- 


Table III. Decrease in Liquor Amnii While Patient Was Under Observation 
Case 56424. Poeyhydramnion 


3-24-32 


1610 C.C. 

3-25-32 


1655 c.c. 

4- 8-32 


932 C.C. 

5- 2-32 


417 c.c. 

5- 5-32 


490 c.c. 

5- 5-32 

Delivery 

350 c.c. Actually collected 


vals, during the last six weeks of pregnancy, the amount of fluid consist- 
ently diminished (see Table III ) . At the time we ruptured the membranes 
at term, there was present only one-fourth the fluid calculated at the first 
observation. Clinicall 3 ’-, she presented a moderate poljdiydramnion when 
first seen, which gradually disappeared. The amount of fluid maj’- be en- 
tirely dependent on maternal metabolic processes, which when altered give 
rise to pathologic quantities. 

The rate of absorption of various colored solutions from the amniotie 
cavity of the rat and their transmission through the placenta has been re- 
cently studied by Boucek and Renton. We shall make similar studies on 
the human being because of the feasibility of injecting colored solutions 
into the amniotie cavity without disturbing the pregnancy. The Congo 
red used in our experiments entirely disappears from the amniotie fluid 
and finds its way into the maternal circulation, although the rate of absorp- 
tion for this dye is slow. Many physiologic problems on the interrelation- 
ship between the maternal and fetal organisms have been suggested by this 
additional method of study. 


REFERENCES 

Bowntree, Keith, and Geraghty : Arch. Int. Med. IG: 547, 1915. Lehn.; Ztsclir f 
78: 670,1916 Tamsig, Fred G. : Am. J. Obst. & Gynec. 14: SOs', 
1927. Knetner, Otto: Ztschr. f. Geburtsh. ti. Gynak. 20 : 445, 1890. Polano, 0.: Ber. 

J?’ 3: 1, 1924. Hinselmann,: Biol. u. Path. d. Weibes! 

D AoolPtnn^®**a’r' Williams, J.Whitrxdge: Obstetrics, New York, 1930* 

Soltermann, Carl: Zentralbl. f. Gynak. 46; 2536 1924. 
OeBee, J. B.. Principles and Practice of Obstetrics, Philadelphia, 1930, W B Saunders 
Company. Boxicelc, Charles M., and Benton, Arthur D.: Surg. Gynec. Obst. 54: 906, 

5841 Maryland Avenue. 


( 




HYPERTHYROIDISM ASSOCIATED WITH PREGNANCY*' 

Frederick A. Bothe, ]M.D., Philadelphia, Pa. 

'^HE increased secretion of the thyroid gland is the most readily ob- 
served of the physiologic changes which occur in the activity of the 
endocrine glands during pregnancy. Our present Imowledge does not per- 
mit us, in many instances, to differentiate clearly between this physiologic 
hyperactivity and hj’perthyroidism. In this paper I wish to discuss the in- 
fluence of hyperthjmoidism on pregnancy, and the diagnosis and treatment 
of hyperthyroidism associated with pregnancy. 

Apparently the state of pregnancy demands an increased secretion of 
the thyroid gland. Observations by Fleischer,^ Seitz,- and others, and ex- 
perimental studies by Anselmino and Hoffman,®- •* and Davies, Meakins, 
and Sands,® have supported this belief. 

Hyperthyroidism whether it is due to a toxic adenoma or exophthalmic 
goiter, results in relative sterility. Estimations of the percentage of nor- 
mal fertility have been given in studies by Gardiner-Hill,® Mussey, Plum- 
mer, and Boothby,' and Mussey and Plummer.® HjTperthyroidism not only 
decreases normal fertility but is a serious complication for a successful 
termination of pregnancjL This was noted in studies made by Gardiner- 
Hill,® and Seitz.® 

A follow-up study was made of the female patients between the ages of 
nineteen and thirty-five, who were operated upon at the Presbyterian Hos- 
pital on the services of Doctors Jopson, Hodge, and Speese, between Jan. 1, 
1926, and Jan. 1, 1931, to determine the effect of thyroidectomy upon 
fertility and subsequent pregnancies. There were 48 patients in all. 
Eleven were not married at the time of operation. Of the remaining 37 , 
26 or 70 per cent gave a history of one or more miscarriages before thy- 
roidectomy was performed. Only twenty patients could be traced. Of 
these 20, 10 have had successful pregnancies and one. has had two success- 
ful pregnancies. There has been one miscarriage. Two patients operated 
upon during pregnancy have each had one successful pregnancy since 
operation. 

Patients suffering from hyperthjrroidism complicating pregnancy are 
divided into two groups: (1) those of mild toxicity, and, (2) those of 
severe toxicity. In both groups toxic adenomas and exophthalmic or 
hyperplastic toxic goiters occur. In cases of mild toxicity the most con- 
stant symptoms are increasing nervousness, taclij-'cardia, tremor, slight 
exophthalmos, definite emotional instability and fatigue. The basal meta- 
bolic rate is elevated to plus 30 to plus 35. These figures are only approxi- 
mate as the rate varies. In cases of severe toxicity these symptoms are 

*Read at a meeting’ of the Obstetrical Society of Philadelphia, October 6, 1932. 

62S 



BOTHE : HYPERTHYROIDISM 


629 


more pronounced, the symptoms and findings in the peripheral circulation 
are more advanced, and the derangement of the sympathetic nervous sys- 
tem as manifested by nausea, vomiting, and diarrhea is evident. In both 
groups toxic adenomas are usually seen later in life. This is of significance 
in our judgment as to treatment. 

Certain atypical patients have clinical manifestations which warrant' a 
study of the degree of activity of the thyroid gland during pregnancy. 
This study should be made in patients having cardiovascular symptoms, 
particularly tachycardia, which are out of proportion to the pathologic 
findings elicited by an examination of the cardiovascular system, as we 
know that this increased activity of the thyroid gland is not infrequently 
the cause of such symptoms in the nonpregnant woman. Two patients 
came under my observation with unexplained tachycardia during the early 
months of pregnancy, who subsequently were found to be suffering from 
moderately severe hj^perthyroidism. Such a study may also be of assist- 
ance in the treatment of cases of toxemia of pregnancy which do not re- 
spond to the usual therapeutic measures. Falls® reported three patients 
who were referred to the hospital with the diagnosis of hyperemesis gravi- 
darum who proved later to have exophthalmic goiters, with an acute crisis. 
Davis and Harper^® reported a similar ease. Falls® had four additional 
eases that had concomitant symptoms of eclamptogenic toxemia. Of the 
patients seen at the Presbyterian Hospital with hyperthyroidism either in 
the pregnant or nonpregnant state, a high percentage gave a history of 
prolonged nausea and vomiting during their previous pregnancies. 
Though only eleven cases have been observed, they have all noted a great 
decrease in the morning nausea and A^omiting in pregnancies subsequent 
to thyroidectomy. Stander and Pecltham“ in a careful study, found the 
basal metabolism was higher in the toxemias of pregnancy. 

An illustrative case was Mrs. H. M., thirty-two years of age, admitted to the Presby- 
terian Hospital with a diagnosis of hyperthyroidism associated with pregnancy. She 
had suffered from nausea and vomiting for four months. Many days she vomited all 
food taken by mouth and at times spent seven to ten days in bed. A history and physical 
examination revealed that she was in the sixth month of pregnancy complicated by a 
severely toxic adenoma. After rest in bed and Lugol ’s Solution, a subtotal thyroidec- 
tomy was performed. The patient made an uneventful convalescence and was symp- 
tomatically improved. At follow-up clinic six weeks after discharge from the hospital, 
the pulse was eighty, the symptoms had disappeared and the emotional stability was 
satisfactory. The basal metabolic rate was plus twenty-four which is within normal 
limits at the beginning of the eighth month of pregnancy. She was admitted to the hos- 
pital just before term because of hypertension; the blood pressure ranging from 
160/80 to 170/90. No symptoms of toxemia developed and she was delivered of a nor- 
mal child at term. She was again pregnant in December, 1931, which was subsequent 
to thyroidectomy. In this pregnancy nausea was present for two weeks in the second 
month, but no vomiting occurred. In the seventh month a careful examination revealed 
no evidence of recurrence of hyperthyroidism. At the first reading the blood pressure 
was found to be 166/88, but after the patient was allowed to calm down for a few 
moments, it fell to 130/80. Tl)e pregnancy terminated successfully at term with no 
complications. 



630 


AMERICAN .TOURNAE OF OBSTETRICS AND GYNECOLOGY 


In the last decade the use of iodine as a therapeutic measure in toxic 
goiter has been placed on a firmer basis and thyroidectomy has been per- 
formed more frequently during pregnancy. Series of patients in whom 
thyroidectomy has been performed during pregnancy, iiave been reported 
by Mussey and Plummer,® Laliey,^= Pabrini,'® and Palls.® The results in 
these sei’ies were most favorable and demonstrated that thyroidectomy per- 
formed during pregnancy is not as hazardous a procedure as it was once 
thought to be. 

At the Presb 3 derian Hospital, ten patients have been seen with hj’^per- 
thyroidism complicating pregnancy. Eight were in the group of severely 
toxic goiters and two in the group of mild toxicitv. The two mild cases 
were treated mediealfv with a successful termination of pregnaucjL Of 
the eight cases of severe toxicit.v, two refused operation, one miscarried in 
the hospital before surgery could be performed, and in the remaining five, 
a subtotal thjToidectonn’- was performed, three being operated upon in the 
first four months of pregnancy and two in tlie sixth montli. In the five 
cases opei’ated upon, the pregnancies were sueeessful at term. 

It is not infrequentlj' stated in the literature that permanent relief is 
obtained in manj’' cases of hj'perthyroidism after the termination of a suc- 
cessful pregnancy. Gardincr-HilP stated that in 50 per cent of his series, 
improvement was maintained thereafter. At the Presbjderian Hospital 
we have seen five patients all of whom had had a normal deliveiy at term 
in whom the sjunptoms of h.yperthj'roidism persisted postpartum. Duo 
time was allowed for the readjustment of the glandular function. In four 
cases operation was advised during the second and third months after de- 
liverjL Two refused operation and have not been traced. Two patients 
were operated upon, and their convalescence was uneventful and there has 
been no recurrence of the disease. 

The fifth case was a woman, twentj' years of age, admitted to the Presbyterian Hos- 
pital March 17, 1932, with a diagnosis of exophthalmic goiter in an acute crisis. In 
tlie past history slie had had two normal children, one in August, 1930, and the second 
on December 27, 1931. During tlic last six weeks of the second pregnancy, moderately 
severe hyperthyroidism developed. The delivery and puerperium were normal in e%’cry 
way, except for the presence of symptoms of hyperthyroidism. These symptoms pro- 
gressed after delivery, medical measures were instituted, and in two weeks, which was 
five weeks postpartum, the symptoms had subsided, the pulse was 80 and the basal 
metabolism was zero. She was then discharged with instructions to return to the dis- 
pensary for close observation. The patient did not return, however, for six weeks, and 
at that time she was in a severe thyroid crisis. She was admitted to the hospital and 
treated by rest in bed, sedatives, and Lugol's Solution, in large doses. The response to 
these measures was not sufficient to -warrant a partial resection of the gland, so five 
weeks after admission a ligation of the right superior pole was performed. She re- 
acted poorly to this procedure and a bilateral ligation eould not be attempted. In six 
weeks when impro-vement was apparently at its height, a right lobectonij was done. 
The patient immediately went into a severe postoperative crisis, did not respond to 
tlie routine therapeutic measures for this complication, and died on the third post- 
operative day. A summary of the autopsy report stated that the thymus iras present 
and weighed 22 gm., and there was a tendency to general lymphoid hj perphasia 



BOTHE : HYPERTHYROIDISM 


631 


throughout the various lymph nodes of the body. A marked hypoplasia of the cardio- 
vascular system was present. These five cases show rather conclusively that we should 
not he too strong in our behef that the symptoms of hypertliyroidism will be perma- 
nently relieved after a normal delivery at term. A complete study of the activity of 
the thyroid gland should be made at intervals after delivery, in patients who had 
hyperthyroidism complicating a pregnancy. 

It has been shown that patients who have clinical evidence of a physio- 
logic hyperactivity do better on small doses of iodine during pregnancy. 
This therapeutic measure in conjunction with increased rest is usually all 
that is necessary. In mildly toxic cases medical treatment is instituted 
first. The patients are placed at rest in bed, given sedatives, Lugol’s Solu- 
tion, ten drops, three times a day, and isolated from any external stimulus 
that may upset their emotional stability. If improvement or complete re- 
lief of symptoms is maintained, medical care is continued during preg- 
nancy. Careful study of these eases is essential in the first three or four 
months, because if there is a recurrence of symptoms, though medical 
measures were carried out, a subtotal thyroideetomj’- is indicated. In mild 
border-line eases ivliieh occur early in pregnancy, surgery is recommended 
more frequently in toxic adenomas than exophthalmic goiters. Toxic 
adenomas occur later in life as a rule and the heart muscle is not as likely 
to be able to withstand the myocardial changes and the strain of a delivery, 
as it is earlier in life. If a mild ease is seen late in pregnancy, the thyro- 
toxicosis can usually be controlled by medical measures. The activity of 
the thyroid gland should be studied after delivery and these studies will 
determine the proper treatment. 

In severely toxic eases, our treatment should be directed at the thyroid. 
A subtotal thj'^roideetomy is indicated after preoperative preparation of 
the patient. This is particularly true if the patient is seen in the first five 
months of pregnancy. In extreme eases this procedure may not be pos- 
sible, and a unilateral or bilateral polar ligation should be done depending 
upon the patient ’s condition. We now know that a general anesthesia and 
major surgical procedure which is not directed at the thyroid, performed 
upon a patient suffering from h3q)erthyroidism, results fatally in many in- 
stances. Cases have been reported in which tonsillectomy and extraction 
of the teeth have resulted fatally in patients suffering from hyperthy- 
roidism. Lahey® advises deferring any major surgical procedure until six 
months after thyroidectomy. For these reasons many feel that thera- 
peutic abortion should not be performed in this group of patients. 

It is suggested that patients having symptoms or clinical findings which 
point to an increased activity of the thj'-roid complicating pregnancy, 
whether it be of the physiologic or pathologic type, should be studied bj’ 
both the obstetrician and the surgeon. The patient should be seen by both 
of them at intervals during pregnancy and after delivery. By this type of 
management both the obstetrician and surgeon would see a greater num- 
ber of this p’oup of patients, and a more thorough understanding would 
develop which would assist us in solving the diverging viewpoints which 



632 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


now exist as to the proper therapeutic measures which should be instituted. 
By follow-up studies we could then determine more accurately the remote 
results from the adoption of such measures. Great progress has been made 
by such a comhhicd management when diabetes complicates pregnancy, 
and a similar result should occur by such cooperation. 


REFERENCES 

(1) Fleischer, A. J.: Alt. J. Oust. & Gynec. 22: 273, 1931. (2) Seitz, L.: Die 
Storungen der inneren Sekretion in ihren Bezieliungen zu Schwangerschaft, Geburt uad 
Wochenbett. Verhandl. d. dcutseli. Gcs. f. Gj'n. (3) Anselmino, E. J., and Hoffman, 
F. : Arch. f. GjTiiik. 145 : 95, 1931. (4) Anselmino, K. J., and Hoffman, F. ; Arch. f. 

Gyniik. 142: 289,1931. (5) jDavics,H.W.,Mca'kins,J., and Sands, J.: 'E.ea.Tt2: 299, 
1924. (6) Gar diner -Hill, H.: Lancet 1: 120, 1929. (7) Mussey, F. D., Plummer, 

W. A., and Boothhy, TF. M.: J. A. M. A. 87: 1009, 1926. (8) Mussey, E. J)., and 

Plummer,W. A.; J. A.M.A.97: 602, 1932. (9) Falls, F.H.: Am. J. Obst. & Gynec. 
17 : 536, 1929. (10) Davis and Harper: (Quoted by Falls, P. H.) (11) Stander, 

H. TF., and Pechham, I.: Johns Hopkins Hosp. Bull. 38: 227, 1926. (12) Lahey: 

Proc. Internat. Assemb. Inter. State Post Grad. M. A. North America, 1930, 6: 
343-345, 1931. (13) Fahrini, G. S.: Canad. M. A. J. 23: 645, 1930. 

ABSTRACT OP DISCUSSION 

DB. COLLIN POULKBOD. — The view is gaining that thyroid conditions must be 
Iiandlod together by the thyroid clinician and the obstetrician. This will lead to 
bettor results. 

It seems to me that the study of young women before marriage and pregnancy 
should include a study of the thyroid. It is a well known fact that in pregnancy read- 
ings are a little more difficult to secure, and a more accurate reading can be taken 
when there is no pregnancy. I have sent pregnant patients to three different clinics, 
and had three different readings; and the answer was that the patient was not quiet 
enough to give a good reading. 

"We feel that the study of the thyroid activity of young girls is a very grave necessity 
in preparing for pregnancy. 

There were other patients in whom enough thyroid extract would encourage them 
to be less nauseated and go on to term normally. 

DE. CHARLES MAZER.— It seems paradoxical that both extremes of thyroid func- 
tion are productive of the same symptoms in relation to menstruation and pregnancy, 
that is, delayed and prolonged bleeding or abortion. 

Amenorrhea, dysfunctional uterine bleeding and the tendency to repeated miscar- 
riages, associated with a low basal metabolism, are frequently relieved by the adminis- 
tration of thyroid tissue. 

Hyperthyroidism, as seen in exophthalmic goiter, on the other hand, often produces 
the same menstrual and gestational symptoms. Simple hyperthyroidism, however, is 
usually free from menstrual disorders and the tendency to abort. It therefore seems 
that the excessive production of thyroxin is not the responsible agent and that exoph- 
thalmic goiter is a severe constitutional disease with goiter symptoms and not simply 
a form of hyperthyroidism. 

Experimentally, Weichert has shown that injections of thyroxin into adult rats sup- 
press estrus through excessive stimulation of the anterior pituitary lobe which, in turn, 
produces hyperluteinization and a state of pseudopregnancj'. Clinically , bower er, the 
amenorrhea of women suffering from exophthalmic goiter cannot be explained on the 
basis of a persistent corpus luteum and a state of pseudopregnancj'. 



CONCERNING DEATH OP THE PETUS IN PREGNANCY*' 

J. Stuart Lawrance, M.D., Philadelphia, Pa. 

(From the OTistetric Department, St. Mary’s Sospital) 

T his paper has two purposes. The first is to report the evidence sup- 
porting a theory that starvation of the fetus in utero, due to imperfect 
osmosis through a definite type of abnormal placenta, is, in some cases, the 
cause of fetal death ; together with a description of the therapy devised to 
overcome this defect. The second purpose is to present a method for the 
early diagnosis of fetal distress from any cause in pregnancy. 

I. INTRAUTERINE STARVATION DUE TO IMPAIRED PLACENTAL OSMOSIS OP 
NUTRIMENT IS ONE OF THE CAUSES OP PETAL DEATH IN PREGNANCY, 

AND THE THERAPY BASED ON THIS CONCEPTION 

Some of the causes of fetal death in pregnancy are known. Syphilis, 
maternal nephritis, and lead poisoning are established causes. Severe in- 
fluenza, scarlet fever, and cardiac lesions of the mother are suspected. But, 
in any large series of pregnancies observed and accounted for, from the 
fourth month on, there will usually be found instances of a few fetal deaths 
before the onset of labor where neither syphilis, nephritis, lead, influenza, 
or cardiac lesion have played a part and whose causes are unknown. It is 
with the cause of some of these unloaown deaths that we are concerned. In 
presenting the evidence, the question arose whether all of it should be used 
or simply a brief statistical tabulation presented. The former course has 
been chosen, despite added length and diversion of attention, because not 
only is the evidence cumulative, but the history of the initial case of the 
series is significant both as an unusual vital experiment and as a starting 
point for the working hypothesis. 

This investigation was commenced in 1919 when the following clinical 
problem presented itself for solution. A woman thirty-four years of age 
stated that of five previous pregnancies, the infants of the two last had died, 
one in utero toward the end of pregnancy, one just after birth ; and, that 
being again pregnant for the sixth time desired, if it were possible, to know 
the cause. The obstetric history was as follows : 

The patient, in 1919 a para vi, had promptly conceived, easily carried and quite 
easily delivered spontaneously, the first two infants who were sound specimens, alive 
in 1931 ; and had progressed through a normal puerperium in each. In the labor of 
the third infant, however, an unknown complication had occurred which had resulted 
apparently in a puerperal infection of some severity. Two pregnancies had followed 
the puerperal infection. In the first of these two, the infant had died toward the end of 
pregnancy ; in the second the infant had died just after birth. The first of these still- 
births was apparently well developed. The second was undernourished, wizened, and 
weighed less than six pounds. At the time of consultation (1919), the patient was 

*Read at a meeting of the Philadelphia Obstetrical Society, October 6, 1932. 

633 



634 


A^IERTCAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 

in about tlie tlnrd nioiith of the current or sixth pregnancy. A thorough study of a 
detailed history and a painstaking general, chemical and serologic exainiiiation estab- 
lished that the patient was then a healthy woman, and did not reveal the presence of any 
of the common causes of fetal death in utero, either in pregnancy, i. e., syphilis, nephri- 
tis, lead; or in labor, i. e., contracted pelvis, etc. The only abnormalities found were 
an erosion surrounding a deep bilateral laceration of the cervix, producing leucorrhea, 
and internal hemorrhoids, one of which was a fibrous ball. There was, in 1919, no 
other discoverable lesion. Therefore, in the absence of any demonstrable or half- 
demonstrable cause for these deaths, a hypothesis of intrauterine starvation was erected 
to serve as a working diagnosis, based on the following pure assumptions, the validity 
of njjicli the course of this c«ase and the additional evidence, clinical and therapeutic, 
will have to support. It was assumed (a) that an endometritis developed after the 
third pregnancy because there was known to be an erosion and a leucorrhea, and be- 
cause of the infection that had occurred in the third puerperium; (b) that a chronic 
placentitis had e.xistcd in each of the fourth and of the fifth pregnancies due to the 
endometritis; (c) that such a placent.a would be so poor an osmotic membrane, so 
poor a filter, that even carbohydrates’ in ordinary amounts would find difficulty in filter- 
ing through it. It was imagined that the placentitis might have been somewhat of the 
syphilitic type, consisting of an increase in and coarsening of the connective tissue in 
both the maternal and fetal portions of the placenta, and of a decrease in arborization. 

A successful therapy based on this hypothesis would depend on finding and supply- 
ing nourishment in a form that could most easily osmose through such a thickened 
placenta. It was believed that an excess of carbohydrates might be capable of filtering 
through such an obstruction in amounts sufficient to nourish the fetus. It was there- 
fore decided to place the i)atient on an excessively’ rich but not exclusive carbohydrate 
diet. This was before the time that Titus’ had demonstrated the value and use of 
glueose intravenously, but the ob.iect was obtained then by requiring cereals, sugar, 
honey’, molasses, potatoes, simple puddings, etc., in daily excess of the amounts usually 
consumed by’ this patient and in addition one-half pound daily of either hard candy or 
bonbons. Exercise, to the extent of three to five miles walking a day was required to 
prevent storage of the unused carbohydrates. These two requirements were the only 
means prescribed in addition to the usual hygiene of pregnancy. Subject to this diet 
and degree of exercise, the sixth pregnancy’ went to full term ■with a live fetus and 
labor resulted in a live baby, vigorous and without defect, weighing 8 pounds 14 ounces. 
In the course of this case, blood sugars rvere not determined (in later ones they were 
and in all such cases at the present time, blood sugars are determined at fixed intervals 
and hours), but regular weekly analyses of twenty-four-hour collections of urine for 
glucose were made and, strikingly enough, did not once disclose a trace of glucosuria. 
Nor did the patient become fat. On the contrary’, she was physically better at term 
than at three months. Both of these phenomena could have been due to the vigorous 
exercise required, but they could also have been due to consumption of the excess earbo- 
hy’drates by’ the fetus, leaving little to be stored as maternal fat. There W’as no edema, 
constipation or headache, but there W’as a lack of appetite. 

The labor was the usual three-hour labor of this patient, and spontaneous. The 
placenta W’as expelled complete as ■were the membranes, but was delay-ed fifty- minutes. 

It -was w’ashed and flushed. Macroscopically, it was a small placenta of a very few 
cotyledons each one separated from the other by- a clearly- visible band of -what appeared 
to be connective tissue. The cotyledons w-ere hard rather than spongy and were not 
plump. The color was a blue gray. There were but few infarcts either white or red. 
Microscopically’, the diagnosis was chronic placentitis, a term meant to sum up a picture 
in which there were ; first, an excess of connective tissue; second, a decrease in arboriza- 
tion; third, a coarsening of both the maternal and fetal elements; fourth, niajiy areas 
where the syncytium could not be demonstrated. 



L.AWRAMCE: DEATH OF FETUS IN FREGNANCY 


635 


It was felt that the value of the working hypothesis of fetal starvation due to im- 
paired placental osmosis had keen increased both by the favorable clinical result and 
by the character of the placenta, and that its status had advanced to the stage of a 
theory, a conviction that the subsequent course of this case confirmed. 

Six months after the sixth labor, the cervix was amputated, the uterus carefully 
curetted and every effort made to eradicate the endometritis, and so successfully that 
the leucorrhea ceased. A year and a half later, the patient was delivered of her seventh 
infant and again it was alive. Careful examination of the placenta of this ovum and 
comparison with slides of that of the sixth pregnancy, demonstrated an almost normal 
placenta. At a later date, an eighth infant was born alive, the placenta being normal. 
It was believed that the clinical results and the compailson of the sixth with the seventh 
and the eighth placentas, proved the original hypothesis correct, and it was therefore 
concluded as a fact in this particular case that : 

1. The cause of the successive intrauterine deaths of the fetus was starvation. 

2. The coarsened fibrous placenta had prevented osmosis. 

3. The carbohydrates could osmose through. 

It is true that this was hut one ease and that we were founding a theory 
thereon, but owing to the large number of pregnancies undertaken by this 
woman, it should rather be regarded as a series of eight vital experiments 
with one common factor or control, an identical mother. 

Naturally this ease interested us a great deal, and we determined to in- 
vestigate our material to find out whether the history described above rep- 
resented a single, perhaps accidental, case of starvation of the fetus or a 
regularly recurring, if rare, cause of death in any large series. The first 
step was to determine whether in the past instances of intrauterine fetal 
death in pregnancy had occurred without demonstrable cause, i. e., syph- 
ilis, nephritis, or lead. We found that each year such cases had occurred 
but not frequently. Since 1922, we have been routinely studying, and ob- 
serving carefully, the apparent condition in utero of all fetuses -, the causes 
of all deaths in pregnancy ; and various methods of determining distress. 
Considerable evidence has accumulated in proof of our theory, and some 
evidence that is not favorable. To illustrate the existence and incidence 
of placentitis as a cause of distress among infants living and dead, the fol- 
lowing analysis of 645 pregnancies of a consecutive series studied week by 
week is submitted, which reports the favorable and unfavorable data. 

All of the morbid processes maternal and fetal, associated with each fetal 
death especially those dying in pregnancy before the onset of the act of de- 
livery (be it premature or fullterm labor) are set down. The placenta of 
each ease in this series, living and dead, was closely inspected macro- 
scopically by a competent observer and microscopically when in his opinion 
it was indicated. No placenta has been described as being the seat of 
placentitis without a microscopic study. 

Number of pregnancies in this series was 645 

Number of infants to be accounted for was 649 

Number of stillbirths from the second lunar month of 

pregnancy until full term was 12 

Number of neonatal deaths was 18 

Number of infants alive on the tenth day was 619 



636 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


Considering first the stillbirths (second lunar month to full term) , seven 
of whom manifested distress in pregnancy, we find the following morbid 
processes associated : 

STILLBIRTHS MANIFESTING PETAIj DISTRESS IN PREGNANCY 

One case 4 to 5 lunar months, placentitis clironic, toxemia mild stage.* 

One case 7 lunar months, placentitis acute. 

One case 9 lunar months, compression of cord. 

One case 9 lunar months, placentitis chronic. 

One case 9 lunar months, placentitis chronic, myxomatous degeneration of placenta, 
abruptio placentae prcviae. 

One case 10 lunar months, toxemia severe stage, renal type.* 

One case 10 lunar months, placentitis, toxemia severe stage, hepatic type.* 

STILLBIRTHS NOT IMANIFESTING FETAL DISTRESS IN PREGNANCY 

One case 10 lunar months, strangulation. Distress manifested in labor. 

One case 2 lunar months, infantile uterus. 

One case 8 lunar months, placentitis chronic, epilepsy. 

One case 9 lunar months, abruptio placentae, trauma. 

One case 9 lunar months, occiput posterior, Scanzoni. 

Considering the eighteen neonatal deaths, four of whom manifested 
distress in pregnancy, we found the following associated morbid processes : 

NEONATAL DEATHS MANIFESTING FETAL DISTRESS IN PREGNANCY 

One case 7 lunar months, placentitis chronic, weight 3 pounds 15 ounces. 

One case 10 lunar months, no kidneys in fetus ; lived a few minutes. 

One case 10 lunar months, toxemia mild stage,* only association. 

One case 10 lunar months, placentitis, eclampsia, infantile subdur.al hemorrhage. 

NEONATAL DEATHS NOT iMANIFESTING FETAL DISTRESS IN PREGNANCY 

One case 7 lunar months, endometritis, weight 5^/^ pounds; distress originated in 
pregnancy. 

One case 9 lunar months, unknown; distress originated in labor. 

Five cases 10 lunar months, subdural hemorrhage; distress originated in labor. 

Three cases 10 lunar months, infantile congenital defects compatible with intra- 
uterine, incompatible with extrauterine life ; distress originating in the neonatal period, 
vis dextrocardia, spina bifida, no interventricular cardiac septum. 

One ease 10 lunar months, congenital defect, melena ; placenta previa, distress orig- 
inating in pregnancy. 

One ease 10 lunar months, one twin; distress originating in neonatal period. 

One case 10 lunar months, unknown ; toxemia severe stage; distress originating in 
labor. 

One case 10 lunar months, enteritis; distress originating in neonatal period. 

CoDsidering fiuafiy the 619 infants alive on the tenth day after birth, 
nine of whom manifested distress in pregnancy, the following associations 
were found : 

LIVING INFANTS MANIFESTING FETAL DISTRESS IN PREGNANCY 

Three cases, chronic placentitis, the only association. 

One case, acute failure of maternal cardiac compensation. 



LAWBANCE: DEATH OF FETUS IN PREGNANCY 


637 


One case, placentitis and hydrorrhea. 

One case, maternal anemia, toxemia mild stage. 

One case, trauma the only associated phenomenon. 

One case, acute maternal bronchitis in pregnancy. 

One case, maternal cardiac, mitral, lesion. 

LIVING INFANTS NOT MANIFESTING FETAL DISTRESS IN PREGNANCY 

Four cases, placentitis, the only association. 

One ease, placentitis and diabetes. 

One ease, placentitis and congenital defect. 

Thus we find that among 7 stillbirths manifesting distress in pregnancy, 
there were associated 5 cases of placentitis, and that twice placentitis was 
the only associated lesion. Among 5 stillbirths that did not manifest dis- 
tress in pregnancy, placentitis is associated bnt once. Among 4 neonatal 
deaths where distress was manifested in pregnancy, placentitis was an as- 
sociated finding twice and once the only finding. Among 14 neonatal 
deaths where distress was not manifested in pregnancy, no ease of placen- 
titis was found at all. Among 9 living infants who manifested distress in 
pregnancy, placentitis was an associated finding in four cases and in three 
cases the only finding. 

However, among 6 living infants not manifesting distress in pregnancy, 
placentitis was found 6 times, and in 4 cases was the only finding, being in- 
stances that do not support the theory. In view of the very positive rela- 
tion that seems to exist between the stillbirths, the neonatal deaths, and 
the 9 living infants manifesting distress (not due to labor or congenital de- 
fects) and placentitis, we attribute the incidence of placentitis in the group 
of 6 living infants not manifesting distress to cases of placentitis of less de- 
gree. In this series of 645 pregnancies, there were but 6 instances of ma- 
ternal syphilis. MaternalandcordWassermanns were made on all. Syph- 
ilis is considered to be present if either there is a plus-three or plus-four 
Wassermann, or if, in the absence of a positive AVassermann, there is clin- 
ical evidence of syphilis. Among the 6 cases of syphilis in this series it 
happened that there were no stillbirths, no neonatal deaths, and no in- 
stances of fetal distress in pregnancy. It will be noted that there are sev- 
eral instances of renal disturbances. The examination of the blood dis- 
closed no evidence of lead poisoning in any case. 

THERAPY 

The reason for the excess carbohydrate therapy of those eases of fetal 
distress in pregnancy that are due to impaired placental osmosis resulting 
in starvation, has been given. In our opinion, it is valid regardless of 
whether carbohydrates are the sole food substance filtered through the pla- 
centa as Siemens^ has indicated or whether fats and proteins also filter 
through. In applying the therapy, two things must be kept in mind ; first, 
as soon as fetal distress due to this cause has been diagnosed, carbohydrates 
must be very quickly supplied in excess, in a form and by a method that in- 



638 


AMERICAN JOURNAL, OP OBSTETRICS AND GYNECOLOGY 


sures tlie most rapid osmosis possible through the placenta in the largest 
possible amounts, to enable the fetus to assimilate it at the earliest possible 
moment. It must be continued in this way until the signs of fetal distress 
(q. V.) have eeased. Second, after temporary relief has been secured ex- 
cess carbohydrates must be supplied orally until the pregnancy is over, for 
while the threat to the fetus will continue until delivery, the maternal me- 
tabolism could not stand the tcmporaiy measure long. In regard to the 
method of temporary relief ; it was not until Titus= had by his researches 
discovered the potency of glucose, and perfected methods to take advantage 
of it in the treatment of the toxemia of pregnancy, that we arrived at the 
best way of supplying temporarily the urgent primary relief required in 
fetal distress. This lack of knowledge of method and of physiologj’- ex- 
plains the incidence of stillbirths due to starvation in the series of cases 
chosen for analj'sis by us, and is also one of the reasons for choosing this 
series. It is desired to make it clear that while the method of using glucose 
that we have devised for the temporaiy relief of fetal distress due to starva- 
tion differs from the method devised by Titus for the toxemia of pregnancy, 
our method for this totally different purpose owes its existence to the work 
and research of Titus.- For the temporaiy relief of fetal distress, we ad- 
minister intravenousl}’' from 50 to 150 grams of glucose in from 100 to 
200 c.c. of salt solution in a period of about five minutes; usuallj’’ the 
smaller amount ; and repeat it eveiy four to six hours until the fetal heart 
becomes normal, usuall.y a period of less than twenty-four hours, when the 
infant is in distress due to starvation. 

It is seldom that glueosuria dei'clops or that blood sugar values above 
two hundred develop. One such case developed this year (1931) after 
125 gm. of glucose, the period of glueosuria being four hours, the period of 
blood sugar above two hundred being twelve hours. On the other hand, if 
glueosuria develops after the rapid injection of 50 gm. of glucose, we con- 
sider that the distress is j^robably not due to starvation. 


II. THE EARLY DIAGNOSIS OF FETAL DISTRESS FROM jLNY CAUSE IN PREGNANCY 


It was important to devise a routine method that would elicit evidence 
of fetal distress from anj’’ cause in pregnancy long enough before death to 
make therapy possible. At first we could think of but one method, the fre- 
quent and reliable count of the fetal heart sounds as often as possible by one 
observer. To this end the counting of the fetal heart sounds in pregnancy 
became the duty of the chief and the chief of clinic instead of junior as- 
sistants. The following facts were noted as indicative of fetal distress and 
as trustworthy. 


1. That the fluctuation of the fetal heart rate between 120 and 160, which Tweedy 
liad observed to be wdthin the normal limits in labor, an observation we con rm, 
not the normal fluctuation in pregnancy; in that rates above 150 are abnormal m preg- 
nancy. That rates in pregnancy above 150 or below 120 indicate drstress, when the 
count is made by a competent person for at least a half mmute and confirmed J 
several repeat counts. 



lawrance: death op fetus in pregnancy 


639 


2. That the volume of the sounds of the fetal heart, loud, low, has no significance. 

3. That the rhythm is significant in that if reduplication, dropping of beats, or 
other irregularities of rhythm occurred, it indicated distress. 

4. That the demonstration of a funic souffle, not the placental souffle, indicated im- 
minent death, but that it can rarely be heard. 

5. That there are certain subjective symptoms that are especially significant of fetal 
distress, sufficiently significant to cause particular study to be made of all women com- 
plaining of them; and to cause conviction of fetal distress when calm, stable types of 
women reported their presence. These data were obtained by repeated questioning and 
check of answers with fetal heart rate counts and by final infantile results, over a 
period of several years up to the present time. The s}'mptoms are as follows : 

a. There are one or more periods every day rvlien the fetus is felt by the mother to be 
livelier than usual, and that for each woman these tend to recur day after day at about 
the same time or under the same eireumstanees, but not at the same time for all women. 
Such periods of unusual liveliness are normal. 

b. A period of unusual liveliness at an hour unusual for a particular woman indicates 
fetal distress. Such unusual periods of liveliness will precede a cessation of the feeling 
of ' ‘ life ’ ’ in all cases of intrauterine death of the fetus irrespective of cause after the 
fifth lunar month. In cases of starvation or other causes of slow fetal death, unusual 
liveliness of the fetus at an unusual time will generally precede the cessation of the 
sensation of life by several days. 

e. A period of intensified liveliness at a usual or unusual time, often described by the 
mother as a ‘ ' storm ’ ’ of movement, immediately precedes the cessation of the feeling 
of life. 

METHOD ADOPTED FOR THE EARLY RECOGNITION OF FETAL DISTRESS 

1. Instruct the mother to determine the time when her infant regularly becomes 
more than usually lively. 

2. If a period of activity occurs at an unusual hour, have the mother report within 
twenty-four hours. 

3. If a period of liveliness, usual or unusual, becomes a ‘ ‘ storm, ’ ’ have the mother 
report at once. 

4. Eegular and frequent counts of the fetal heart rate in pregnancy, noting rate, 
rhythm, and souffle. 

Patients reporting liveliness at an unusual hour and those reporting 
“stoians” are hospitalized at once for observation and for treatment. 

Patients whose fetal heart rates are discovered to he abnormal are hos- 
pitalized for observation and treatment even if they do not complain of the 
symptoms. Treatment now consists of the administration of glucose intra- 
venously until either the abnormal phenomenon becomes normal or the 
fetus dies. If successful, they are then placed on an oral excess carbohy- 
drate diet and a definite amount of walking, until pregnancy is over. 

Analysis of the consecutive series of 645 cases used in Part I, all of whom 
received regular prenatal care, will serve to illustrate the reliability of this 
method of diagnosing fetal distress in pregnancy. It should be stated that : 

a. Evidence of fetal distress was regularly looked for throughout the pregnancy of 
each case, using the method described above or parts of it. 

b. Tlie series cliosen to illustrate tlie accuracy of the method consists of a consecutive 
series from 1923 to 1927, thus comprising a period in which the best method of diag- 
nosing fetal distress was being routinely determined and not a series comprising the 
later years which show the method working almost without a failure. 



O’iU AMERICAN JOURNAL OF OBSTETRICS AND GTNECOLOGT 

c. A retrogressive clieck of all cases of stillbirth in which we failed to detect fetal 
distress in pregnancy was made in consultation with the mother to determine whether 
fetal distress had manifested itself unobserved. We found that several times, owing 
to my carelessness or to that of the mother, we had failed to detect manifested signs. 

d. Wo are concerned here solely with a method for diagnosing fetal distress in preg- 
nancy from any cause early enough to permit treatment, and not with the diagnosis 
of fetal distress in labor. Lafertj-’ has reported our view as to the latter in his study 
of the Tweedy Test of Labor. 

c. Specifically, this analysis is offered to show: 

1. The incidence of ascertained or ascertainable fetal distress in pregnancy. 

2. The efficiency of the method of diagnosis by comparing the diagnosed and diag- 
nosablc cases of fetal distress in pregnancy with the number which were undiagnosed 
or undiagnosable. 

Considering first the 12 stillbirths (for details see tabulation) the method 
showed the fetal distress that existed in pregnancy in 7 of the 12. It was 
found that in 5 of the 12 stillbirths, the method did not show fetal distress 
before the onset of deliveiy, be it abortion, premature labor, or fullterm 
labor, 4 of these being premature, 1 fullterm. Studjnng these 5, we find 
that in 2 cases the distre.ss was caused by and stai’ted in labor and so are 
foreign to our problem, while in 8 of them the distress started in pregnancy 
before the act of delivery and therefore must be accounted for. One of 
these was an abortion due to an infantile, nterus, which explains the failui’e 
of the method; one was due to a trauma that was associated with an 
abruptio placentae causing almost immediate cessation of the sensation of 
life, which also explains the failure of the method ; and finally, one was a 
case in which undoubtedly fetal distress in pregnancy had actually existed 
long enough before death for the method to mahe it manifest ; that it did 
not is a positive failure which retrogressive check did not explain. There- 
fore, excluding the stillbirths due to labor and those in pregnancy which 
the method could not he expected to show, it will be found that the method 
showed the distress that existed in pregnancy in 7 of the 8 possible cases of 
fetal distress among the stillborn. 

Considering secondly the 18 neonatal deaths ; in 4 of the neonatal deaths, 
the method showed the distress that originated in pregnancy, one being 
premature, 3 full term. In 14 of the neonatal deaths, the method did not 
show fetal distress in pregnancy before the act of birth. Reference to the 
tabulation in Part I shows that in 7 of these, the distress originated in 
labor ; that in 5, it originated in the neonatal period ; that in 2 cases, the 
distress could have and probably did originate in pregnancy, one of which 
had associated an endometritis but no placentitis. Excluding those cases 
in which distress originated in labor and in the neonatal period, 12 in num- 
ber, we find that the method showed the distress among the neonatal deaths 
that actually did or possibly could have originated in pregnancy in 4 out 

of 6 eases. , • • i. 

Considering now the babies alive at the end of ten days, it is to be re- 
marked that this group does not afford the absolute proof that distress 
existed which is obvious in the group of stillbirths and neonatal deaths ; m 



lawrance: death of fetus in pregnanct 


641 


the absence of death absolute proof of distress fails. But if in a group of 
living babies the method of diagnosis showed fetal distress in pregnancy 
and if there were associated with the manifestation morbid processes, ma- 
ternal or fetal, that would indicate the possibility of distress occurring, 
then the reliability of the warning that the method gave is increased. In 
this group there were 15 cases of very probable fetal distress in pregnancy 
(not in labor) of whom the distress was shown nine times by the method 
long enough ahead to permit of the institution of successful therapy, while 
in six cases the probable distress was not shown by the method. Keference 
to the tabulation of these eases in Part I will show that ; there existed 
among the 9 cases manifesting distress an association of morbid processes 
sufficient to produce the distress; while among the 6 which the method 
failed to show, despite the association of a placentitis and, in 2, other grave 
defects, the method failed absolutely unless, as we believe, the associations 
were not sufficiently extensive or severe to produce distress. Therefore, 
without making any deductions or allowances, it may be said that the 
method indicated distress in pregnancy correctly in 9 of 15 possible eases 
of distress among the born alive, or in 9 of 10 almost certain cases of 
distress. 

To sum up : the method showed existing fetal distress in pregnancy in 
(a) 7 of 8 eases of fetal distress in pregnancy among the stillbirths, (b) 4 
of 6 eases of fetal distress in pregnancy among the neonatal deaths, (c) 9 
of 15 possible cases of fetal distress among the living infants, or 9 of 10 al- 
most certain eases among living infants. 

CONCLUSIONS 

1. There is a type of intrauterine death of the fetus in pregnancy that 
is due to fetal starvation alone, not to syphilis, nephritis, lead, anemia, or to 
cardiac disease. 

2. The starvation is due to the increasing difficulty that the increasing 
amounts of nutriment required to nourish the infant meets in filtering 
through placentas of a definite type. 

3. The placentas of this type are characterized by an increase in con- 
nective tissue and a coarsening of the maternal and fetal elements. 

4. Carbohydrates can filter through such a placenta if given in sufficient 
amounts and in proper form. 

5. The administration of sufficient quantities of carbohydrates in the 
most diffusable form will temporarily relieve the distress, while an excess 
but not exclusive carbohydrate diet will prevent the recurrence of distress. 

6. Obsemmtion of the rate and rhjThm of the fetal heart and attention to 
the reports of instructed mothers regarding the periodicity and quality of 
fetal movements will often indicate the advent of fetal distress in time to 
prevent intrauterine death. 


REFERENCES 


(1) Siemens: Am. J. Obst. 80: 194, 1919. (2) Titus Paul • T A at a at„ i 

20, 1920; Titus, Paul, and Dodds, Paul: Air. J. Obst.’ & Gvnec. 14: 181, 1927* 



G42 


A^IERICAN JOURNAL OF OBSTETRICS AND GA'NECOLOGY 


2iOw, Paul, and Dodds, Paul; J. A. M. A. 91: 471, 1928; Titus, Paul, and Lighthodu, 
A; Am. J. Oust. & Gynec. 18: 208, 1929. (3) La/ertij, John Marshall: Am. J. 

Concerning the St. Mary’s Hospital classification 
of Toxemia, see Latvrancc, J. Stuart; Pa. M. J. 25: 771, 1922; Latvranee, J. Stuart: 
Am. j. Oust. & Gynec. 9 : 351, 1925. 

255 South Sixteenth Street. 


ABSTRACT OF DISCUSSION 

DR. T. L. MONTGOMERY. — Dr. Lawrance iiroscnts three propositions: first, that 
a not uncommon cause of emharrassmont of fetal nutrition in utero is fibrosis of the 
stroma of the placental villi and degencr.ation of the villous epithelium; second, that 
embarrassment of the life of the fetus may be recognized by certain rather char- 
.'icteristic symptoms and signs; and third, that the nutrition of the fetus so embar- 
rassed may be improved by the administration of large quantities of glucose intra- 
venously, and by an increase in consumption of carbohydrate foods. 

As to the first of these propositions it would appear that “fibrosis” is only one of 
several conditions which might give rise to interference with fetal nutrition. One might 
also mention hematoma formation in the jdacenta, and extensive necrosis and calcifica- 
tion of the placenta, both of which conditions are also of rather obscure etiology. 

Upon the basis of my own studies in placental pathology, I would, suggest that 
fibrosis, or a lesion which resembles that condition, is not an uncommon finding. I am 
not sure that this condition as we see it in the placenta is a pathologic entity, or an 
indication of chronic inflammation. Upon examination of the immature placenta at 
the fourth or fifth lunar month of pregnancy, one finds a rather free distribution of 
connective ti.ssue elements in the stroma of the villi. These gradually disappear as 
pregnancy reaches full term, and in the mature organ there remains only delicate 
.strands of connective tissue interlacing between the villous capillaries. One also finds 
normally in the mature placenta atrophy and often a complete absence of a distinct 
epithelial layer surrounding the villi. It would appear highly probable that many 
of these lesions which are classified as chronic fibrosis, and I have freely and often 
used the same term, arc in reality stages of arrested development in the placenta. One 
frequently finds in association with this so-called fibrotic aijpearance a considerable 
amount of edema. This edema may also interfere with the free osmosis or transfer of 
food materials between the maternal and the fetal circulation. 

However, these considerations are not after all the important ones in the discussion 
of Dr. Lawrance’s paper. We must accept the fact that there are numerous conditions 
in the placenta which may interfere with the nutrition and growth of the fetus, whether 
or not these lesions arc of a fibrotic character. We are entirely in sympathy vrith 
Dr. Lawrance’s views as to the recognition of fetal distress durmg pregnancy, and 
wish to commend him upon the painstaking studies which he has made of this condition 
during eight or ten years devoted to gathering material for this paper. 

We find in our orvn experience that pregnant women are most conscious of fetal 
movement when they are at rest, when taking a nap in the afternoon, or upon retiring in 
the evening. If fetal movement is so active as to arrest the attention of the mother 
when she herself is preoccupied wdtli work, then such a phenomenon must be notably 
significant. The other points which Dr. Lawr.ance has mentioned in the recognition of 
fetal distress are also most acceptable. 

Perhaps these observations of Dr. Lawranee’s may lead to findings of even greater 
significance. Intrauterine fetal death of obscure type is frequently met with in pa 
tients of the so-called endocrine type. Possibly the low fasting glucose winch fre- 
quently occurs in thyroid and pituitary insufficiency may be the cause of faulty nutri 
■ tion of the fetus in these instances. 



AN EXPERIMENTAL STUDY OP THE EFFECTS OP INTRA- 
VENOUS INJECTIONS OP HYPERTONIC GLUCOSE SOLUTION 
(50 PER CENT) ON THE CIRCULATION OP THE CAT* 

Vincent P. Mazzola, M.D., and JNIarcus A. Torrey, B.S., 
Brooklyn, N. Y. 

(From the BefartmenU of Obstetrics and Gxjnecology and Physiology, Long Island 

College of Medicine) 

O NE of the greatest problems confronting the surgeon is the treatment 
of shock. Many theories have been advanced as to its cause. Like- 
wise, different opinions are held concerning its treatment. It is known 
that in shock there is impairment of the circulation resulting in stasis of 
blood in the capillaries, transudation of plasma into tissue spaces, deficient 
oxygenation of tissues and diminution of blood volume.’^’ - These physical 
and physicochemical changes will eventually impair the function of the 
heart, due to the extra strain placed upon it by its endeavor to overcome 
the deficient circulation. It follows then that any treatment of the shock 
like state must increase blood volume, aim to diminish circulatory stasis, 
and at the same time provide measures for cardiac support. 

Numerous workers have discussed the injection of various substances, 
and all agree that blood is the best fluid to produce these results. However, 
in the absence of blood, or because of delay in obtaining the proper donor, 
or during high temperatures when blood might cause an undesired reac- 
tion, it is necessary to use a substitute as an emergency measure. Sodium 
chloride, glucose, gum acacia, and various combinations of these substances 
have been recommended. 

It is apparent, from the diversity of opinion, that the perfect substitute 
for blood has not been found. Perhaps there is no such thing. However, 
all are agreed that, at times, emergency measures are necessary. It would 
seem that the addition of large quantities of fluid of any kind is dangerous 
and inadvisable, for it might very well mean the addition of an insur- 
mountable load on an already impaired circulation and weakened myo- 
cardium. This might result in cardiac dilatation with severe heart failure. 
Acacia, at times, produces some unfavorable results, while weak solutions 
of glucose require large quantities. The ideal solution should act to restore 
the circulation by increasing the blood volume in the cardiovascular sys- 
tem without overloading, to improve the nutritive state of the myocar- 
dium, and to tide the patient over until the necessary blood transfusion 
can be given. 

S. at a meeting: of the New York Obstetrical Society, November 

643 



644 


A5IERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


Fearing llie nse of large quantities of fluids intravenously, we"-" liave 
used small doses of 50 per cent glucose (100 to 150 e.c.) clinically with 
good results. In an effort to explain these results, we have studied experi- 
mentally the effects of this solution on the circulation of the cat. Several 
phases of the problem have been studied, and in this paper, we wish to re- 
port the experimental findings on the response of the circulation of the eat 
to various amounts and rates of injection of 50 per cent glucose, and the 
effects, both before and after experimentally induced hemorrhage. 

aiETHOD 

Cats were anest)ietjzed sodium nmytal (0.1 to 0:2 gm.) injected intraperito- 
neally, a carotid cannula inserted and connected with a mercurv manometer. A needle 
was placed in the femoral vein and connected with a burette carrying the solutions. ' At 
times the burette was replaced by .an ordinary Luer syringe when rapid injections were 
desired. 

The amounts of glucose used varied from 2 to 25 e.c., and both slow and rapid in- 
jections were done. The rapid injections were made with a Luer syringe, delivering a 
maximum of 8.5 c.c. per minute. In the slow method the burette was used, the cock 
so set that it delivered .approximately 1 c.c. per minute. 

Blood, for experimental homorrliago, was removed from either the femoral artery or 
vein. 

In order tliat our results might not be confused with volume changes 
per se, we studied a series of cats in which physiologic salt solution was 
given, intravenously, iu varying quantities and rates. Under the condi- 
tions of our experiments, the volume of fluid employed could be disre- 
garded, since the changes in heart rate, pulse pressure, and blood pressure 
were almost insignificant. 


EXPERIMENTAL DATA 

The results of the experiments will be described sepai'ately. Two groups 
are presented ; one in which the blood pressure was unaltered ; i. e., re- 
mained at approximately tlie normal level before the injections were made, 
the other in which an artificial reduction of blood pressure was produced 
hy hemorrhage. 

GROUP I. UNINJURED CATS WUTH NORMAL BLOOD PRESSURE 

Rapid Method. — (10 cats). 

1. Blood Pressure: In this group the blooil pressure changes, following the intra- 
venous injection of 50 per cent glucose, showed four- characteristic phases; namely, a 
(primary) rise, a (secondary) fall, a second rise (tertiary), and a second fall to a 
maintained level. 

The primary rise was small, as a rule, and very transient. We found an average 
rise of 5.66 mm. Hg. The greatest observed rise was 21 mm. Eg, and the smallest 
1 mm. Hg. There rvas no apparent relation between the amount of glucose given and 
the magnitude of the rise. The 4 c.c. injection showed a primary rise of 4 mm. Hg whUe 
the 12 c.c. injection showed a primary rise of only 1 mm. Hg. The duration of the rise 
was ver}' short, lasting three to five seconds as a rule. 



MA.ZZOLA AND TOKREY ; GLUCOSE SOLUTION 


645 


The (secondary) fall followed immediately after the primary rise, was of longer 
duration, and more marked. An average fall of 30.56 mm. Hg was found, the greatest 
being 50 mm. Hg and the smallest 12 mm. Hg. Here there seemed to be some relation 
between the amount given and the extent of the fall. The larger the quantity the 
greater the fall, although there was no definite ratio. In Fig. 3 the amount of glucose 
given was three times as great as the amount given in Fig. 1, but the fall was only 
12 mm. Hg greater, i. e. one and one-half times as great. The secondary fall had an 



INJECTION 

4CC GLUCOSE ^O/T 


O- PRESSURE LINE 


‘bp. 72 Wh Hj. 


AFTER GLUCOSE 


BP. I 06 m.ih 


O-PRESSURE LINE 


B P 9fa n»i. 




lO MIN. PFTER glucose 


0-PRESSURE LINE 
SEC. 


riB.I REBPOWIE TO R>PIO mjeCTION or «CC. BOtVll SLUCOBE 


average duration of thirty seconds, reaching the lowest point in from ten to fifteen 
seconds. 

The tertiary rise developed slowly but steadily, and at its high point was usually well 
above the normal level. The average rise observed from the previous low level was 
39.89 mm. Hg, the maximum 81 mm. Hg and the minimum 16 mm. Hg. Again there 
seemed to be some relation between the quantity given and the magnitude of the rise, 
but again no common ratio. 

Following the high point of the tertiary rise there was usually a slight fall to a level 
which was maintained for a considerable length of time. Many of these cats were ob- 



G46 


AJIERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


served for thirty minutes or longer, and during that time the maintained level con- 
tinued with little or no change. This level was usually above normal. In only one 
case if was below normal (2 mm. Hg below). In our series it averaged 10,66 mm. Hg 
above normal with a maximum of 2C.D0 mm. Hg. 

2. T’lihr Prcstiure; As a rule, the pulse pressure, as recorded by the manometer, was 
greater after glucose had been given. In two cats the change was very slight (normal). 
At the high point it has always been greater than normal. Prom the original to the 




INJECTION 
'l-cc OIUCOSE 50^ 


m 


O- PRESSURE LINE 


B.P. 


t 




END Of OlUCOJt 

INJECTION 


O'PRESSURE LINE 


bTp. TM rtiVt 






lO MIN. AFTE^ OUjeOSt 


O- pressure LINE 




S.Z Pt»POH»t TO SCO* IMJCCTION or 


high point there was an average increase of 2 mm. Hg with an average n.aintained in- 
crease of 1.3 mm. Hg. ^ 

3. Pnlse Pate ; The pulse rate changes were not uniform. In one ease le ‘ 

showed no change, and in another it was above normal, both at the Ingh pom and 
during the maintained level. In one cat the rate at the beginning o 
was very high (295 beats per minute), and the fall observed was grea ( < 

minute). In the majority of cases the rate was slower than normal during the main- 
tained pressure level. 


MAZZOLA AND TORREY : GLUCOSE SOLUTION 


647 


SlolU Method. — (10 cats). 

1. Blood Pressure : In this group the primary rise and secondary fall were always 
absent. Following the injection of glucose the pressure began to rise, slowly and 
steadily, reached a high point, and dropped back a few millimeters to a maintained 
level. The greater the quantity of glucose given the greater the rise, although as be- 
fore there was no definite ratio. There was, however, less difference between the high 
point and the maintained level than in the rapid method. The average high point was 


NO5?M0L 


INJECTION 

lacc glucose 5o> 

O - PRESSURE LINE 




V.V.V.V.V.. . .V.Vl . .V. iVii'iV.’- 

jy^A|j|S£ULlil!lIlVlhUli I'iVlVw k‘ 1 V k i i • . V k i t b I Va » 1 i • r* . * • ■ • ‘ * ^ * * * * 

l-l-J.'l'lTi ^ 

END OF GLUCOSE INJECTION 


O- PRESSURE LINE 



ITS? 


B.p 8oni»i o,min. hftek glucose 


O- PRESSURE LINE 




lOMIN. RFTER. GLUCOSE 


O -PRESSURE LINE 


no. 3 KtlWIHltTO WiB INJCCTIOH or IB CO lOIM OVUCDlt 




26.4 mm. Hg with an average maintained level of 22.4 mm. Hg above normal, a differ- 
ence of 4 mm. Hg as compared with a difference of 2.').23 mm. Hg in the rapid method. 

2. Pulse Pressure: The pulse pressure, as recorded by the manometer, sliowed a final 
increase over the normal. The average increase was approximately the same as that 
observed in the rapid method (1.3 mm. rapid; 1.6 mm. slow). 

3. Pulse Bate: The rate changes were regular, much more so than in tlie rapid 
method. The final rate was always lower than the original rate ; an average decrease of 
14 beats per minute. 


64S 


a:\ierican journal of obstetrics and gynecology 


GROUP II. CATS WITH BLOOD PRESSURE LO^^^RED ARTIFICIALLY BY 

HEMORRHAGE 

In this study the blood pressure was lowered by experimental hemorrhage and trauma, 
again in two groups; one in which the cats had had previous glucose and one in 
which no glucose had been given, and 50 per cent glucose was injected subsequent to 
hemorrhage. 



net so« oiucoie 


O-fItttIWftt ilNl 


1.1- <64. 


• - 


50% iftu^oic cont<L 


O.fJtUfvAC lihC 




ll CC 50% 01u^0>c COM«t. 


O-PRCSSUftC UN& 



ll c C 50*« Olvicose contil 


O-PAESSUftC line 


MAZZOLiV AND TOREEY : GLUCOSE SOLUTION 


649 


Hemorrhage (20 cats) 

A. Without Previous Glucose (10 cats). — 

1. Blood Pressure: Sufficient blood was drauni to produce a marked fall in blood 
pressure. An average of 26.66 e.c. of blood were removed, producing an average fall of 
46.66 mm. Hg. Subsequcutlj’ 6 e.c. of 50 per cent glucose were injected iutravenouslj'. 
Following the glucose injection the ijressure began to rise, slowly and steadily, with- 




^ Rcmov/al T-^cc. blood. 



Q- PRESSURE UNE 


lilts' 41 mm, 



O- PRESSURE UNE 



^ INJECTION 6 cjc. 50 ^ GLUCOSE 
SSldiOBli 


D.K /*r m pi. Htf. 

•* B P. 68 m m 


O -PRESSURE UNE 


■■■■■■■■■■■■■■■■■■I I 

or •ce. lo^n BLUco»r Arrtp 
MCE. ■l.DOD 

out the appearance of either primary rise or secondary fall. Both of these phases have 
failed to appear even when the rate of the injection was rapid. The total rise in blood 
pressure m no instance was sufficient to bring it back to normal. However, there was 
m every case an appreciable rise, and tlie average gain wa.s 32 mm., or almost 70 per 
cent of the loss due to hemorrhage. 

2. Pulse Pressure: The pulse pressure showed a definite increase in every case an 
.•iverage of 1.34 mm. Hg. ^ ’ 




650 


AMERICAN JOURNAL 01^ OBSTETRICS AND GYNECOLOGY 


3. Pulse Bate; The pulse rate was always diminished and maintained at a point 
considerably below novnml (an average decrease of 25 beats per minute). 

B. With Previous Glucose (C c.e. of 50 per cent) (10 cats),— 

1. Blood Pjcssnre: An average of 50.66 c.c. of blood were drawn to produce an aver- 
age fall of 4o mm, Hg. Subsequently 6 e.c. of 50 per cent glucose were injected intra- 



■M.P. *00 •• nj 


jSrMH.MTER PBWlOuS INJECTION 

6 CC so% Gujcose 


CI.PACStUNC UNC 


Bbr - 


socc SLOoa 
REMOVED 


o-PkcBlwPc eine 


’■ 

•! hj I ^ 


IHjeCTlON 
Sit SO%6UlC0S£ 


0>PKCtSvKC LINE 




rSi LimiB.UH;**'"'' W’W * ' ‘ ^ “ 


'■"WUI,! 

ill* 


a-eRitsviie une 



O-PRESSVRC line 



venously. The rise in blood pressure which followed averaged 37.66 mm. Hg or 83 per 
cent of the loss due to hemorrhage (an average difference of S mm. Hg). 

2. Pitlsc Pressure: The pulse pressure showed an increase, although it was not as 
great as in the previous group (3.3 mm. to 3.5 mm.). For ail practical purposes, the 
normal pulse pressure was reestablished. 

3. Pulse Bate; The final rate was approximately the same as normal. In the am- 


MAZZObA AND TORRES; GbUCOSE SOLUTION 


651 


mals, vfluc,R received glucose prior to liemorrliage, the pulse rose slightly, hut readily 
returned to normal after the injection of further glucose. 

DISCUSSION 

The rate of infusion of 50 per cent glucose into the vein of a eat seemed 
to be the factor which determined the blood pressure response to that 
fluid. When the rate of infusion was fast, or at least as fast as 8.5 e.e. per 
minute, the blood pressure showed four definite phases ; namely, a rise 
(primary), a fall (secondary), a second rise (tei'tiary), and a final fall to 
a maintained level. If the rate of injection was slow the first two phases 
were not present. There was an immediate, slow rise, resembling in some 
respects the tertiarj’^ rise in the rapid method, except that it was more 
gradual. Following this rise there was a slight fall to a level that was 
maintained. As has been previously stated, intravenous injections from 
2 to 25 c.c. were given, and the same phases appeared, depending only on 
the rate of injection. Quantity of infusion apparently played no part in 
determining the magnitude of the primarj^ rise. Small amounts fre- 
quently produced the greatest rise. The other phases did show some rela- 
tion to quantity, although no definite ratio existed. When the pressure 
finally reached a level at which it was maintained, it usually was above the 
previous normal. With the slow method of injection it was more apt to be 
higher above normal than with the rapid method. 

AVith either method of injection the pulse pressure showed a tendency 
to increase. The relation of final pulse pressure to normal was about the 
same in both methods. In no instance was it reduced below normal. 

With the rapid method of injection, changes in the pulse rate were not 
regular. As a rule the rate was decreased. In one case it was decreased 
one-third. However, this cat had an unusually high rate at the beginning 
of the experiment, and with that degi*ee of reduction, the final rate was 
still high. AVith the slow method, there was always a slowing of the rate. 

The mechanism producing the fluctuations in blood pressure observed 
with the rapid method of injection is not clear, especially when the saline 
control, given in the same quantity and at the same rate, failed to produce 
any such fluctuations. A comparison of findings in a single case will illus- 
trate the difference. In Case 12, a saline control of 12 c.c. was injected 
prior to the 12 c.c. of 50 per cent glucose. The saline was given at the same 
rate as the glucose which followed. At the beginning of the experiment, 
the sj^stolie pressure was 74 mm. Hg. Twelve seconds after the saline in- 
jection was started the systolic pressure was at 80 mm. Hg, a rise of 6 mm. 
Hg. Foui minutes latex* the systolic pressure was at 78 mm. Hg, ten min- 
utes later 76 mm. Hg, and five minutes later it was 74 mm. Hg, back again 
to the original level. The rise and fall were gradual. Total injection time 
one minute. AVith the injection of glucose the pressure rose to 75 mm. Hg 
and then started to fall. In thirty seconds the sj^stolic pressure was 39 
mm. Hg, a fall of 36 mm. Hg. Four minutes later the systolic pressure 



652 


AaiERICAI'T JOURNAL OF OBSTETRICS AND GYNECOLOGY 


was 120 mm. Hg, and ten minutes later 100 mm. Hg, 26 mm. Hg above 
normal. In other words, following the injection of glucose the blood pres- 
sure went through all four phases characteristic of a fast injection of 
glucose; following the saline the blood pressure went through changes 
rcsemhlinc] a slow injection of glucose. This suggests that the size of the 
molecule of the fluid injected, the concentration, or both are responsible 
for the fluctuations in the blood pressure. The weaker the solution with 
the smallest molecule produced far less change than the more concentrated 
solution with the larger molecule. 

Injection of 50 per cent glucose in eats witli an artificially reduced blood 
pressure produced a characteristic reaction in all eases. There was always 
a rise in blood pressure, an increase or a return to the original pulse pres- 
sure, and a slowing or a return to the original pulse rate. 

In those cases where the blood volume had been actually reduced by 
experimental hemorrhage, there have been certain definite findings. Cats 
that had received glucose previous to bleeding reacted to hemorrhage 
much better, at least from the standpoint of blood j)ressure, than those cats 
that had not received glucose, the final pressure level being much closer to 
the previous normal. At no time did we find anything resembling the 
previously described secondary fall, irrespective of whether the cats had 
or had not received preliminary glucose. In many instances the rate of 
injection was as high as in the rapid injections of Group I. 

The administration of glucose after hemorrhage alwa5'-s increased the 
pulse pressure. The final pulse pressure was closer to the original when 
glucose had been given previous to the hemorrhage than in those cases 
where no initial glucose was given. 

The pulse rate, which was increased by the bleeding, was always slowed 
after the glucose was injected. When glucose had been given before the 
hemorrhage, the final pulse rate was nearer to the normal than when no 
glucose had been given initialljL 

These findings would indicate that the diminished blood pressure, the 
rapid pulse, and the fall in pulse pressure, subsequent to hemorrhage in 
the experimental animal, can be combated, at least in part, by the intra- 
venous injection of 50 per cent glucose. If hemorrhage is anticipated and 
a fortifying dose of 50 per cent glucose is given, the bleeding produces far 
less effect on the circulation than would otherwise be encountered. 

SUMMARY AND CONCLUSIONS 

As a result of our findings we conclude that : 

1. Fifty per cent glucose injected intravenously into eats with a reduced 
blood pressure, produces a final sustained rise in blood pressiu e. 

2. It causes a sustained rise in pulse pressure. 

3. It produces a sustained reduction in pulse rate. 

4. Slow injection is preferred to rapid injection. 



HYAMS; CONIZATION OF THE UTERINE CERVIX 


653 


5, Preoperative injection of 50 per cent glucose diminislies the fall in 
blood pressure due to hemorrhage. 

Note: "We ■wish to express our appreciation, to Mr. Andrew Vanore for his assistance 
during the experimental procedures. 


EEFERENCES 

(1) Blalock, Beard, and Johnson: J. A. M. A. 97: No. 24, 1931. (2) Blalock, 

Bradbnrn, and Hubert; Arch-. Surg. 20: 26, 1930. (3) Fraser and Colwell: A Clin- 
ical Study of Blood Pressure in Wound Conditions, 1917, Mem. No. 2 of the Shock 
Committee, pp. 1-26. (4) Drummond and Taylor : The Use of Intravenous Injections 

of Gum Acacia in Surgical Shock, 1918, Mem. No. 3 of the Shock Committee. (5) Can- 
non: Traumatic Shock, 1923, D. Appleton and Company, p. 177. (6) Bayliss: Intra- 
venous Injection in Wound Shock, London, 1918, p. 24. (7) MacFee and Baldridge : 

Ann. Surg. 91: 340, 1930. (8) Cannon, Walter B.: Acidosis in Shock, Hemorrhage, 
and Gas Infection, and a Consideration of the Nature of Wound Shock, Mem. No. 2 of 
the Shock Committee, 1917, pp. 41-57 and pp. 67-83. (9) Thalhimer, William: 

J. A. M. A. 81: 383,1932. (10) Fisher, D.: Surg. Gynec. Obst. 43 : 224, 1926. (11) 

Beresow, S. L.: Zentralhl. f. chir. 53: 3214, 1926. (12) Padgett and Orr: Surg. 

Gynec. Obst. 46: 783, 1928. (13) Titus, Paul: Tr. Am. Therap. Soc. 29: 154, 1930. 

(14) Wilder and Sansiim, M. D.: Arch. Int. Med. 19: 311, 1917. (15) Bayliss: 

Intravenous Injection in Wound Shock, London, 1918, p. 80. (16) Itous, Peyton, and 
Wilson, G. W.:' J. A. M. A. 70: 219, 1918. (17) Mann, F. 0.: Am. J. Surg. 34: 11, 
1920. (18) Walker and Keith: Proceedings of Staff Meetings of Mayo Clinic 5 : 162, 
1930. (19) Farrar: Surg. Gynec. Obst. 32: 328, 1921. (20) Eandall: J. A. M. A. 

93: 845, 1929 (No. II). (21) Huffman, Lester D.: J. A. M. A. 93: 1698, 1929. 
(22) Lee, B. Van A.: J. A. M. A. 79: 726, 1922. (23) Hanelek and Karsner: J. 
Pharmacol. & Exper. Therap. 14 : 379,1920. (24) Polak, Maszola, and Zweibel: Am. 

J. Obst. & Gtnec. 22: 817, 1931. (25) Leonard Hill, in Schafer’s: Textbook Physi- 
ology Vol. II, p. 75. (26) Kisch, Frans: (27) Hirschfeld, S.: Arch. Int. Med. 

p. 47, January to June, 1931. 

150 Clinton Street. 


CONIZATION OF THE UTERINE CERVIX* 

Mortimer N. Hyams, M.D., F.A.C.S., New York, N. Y. 

(From the Department of Gynecology, New York Post-Graduate Medical School and 

Hospital, Columbia University ) 

‘C'PPECTIVE treatment of chronic endocervicitis is predicated upon a 
correct diagnosis, a clear conception of the histopathologic changes 
following infection, and the utilization of various methods of treatment. 
No single method is universally applicable. Complete removal of an in- 
fected area is an ideal method of cure, but obviously this often carries an 
implication of damage to the integrity of adjacent tissue or impairment of 
subsequent function. Any therapeutic method which approaches this de- 
sideratum vdthout deleterious after results, either struetural or physio- 
logic, seems worthy of consideration. 

In 1926 I made an exliaustive review of the literature of endocervicitis 
and its treatment, and surveyed the then available curative procedures. 
Those which seemed most eflScient were cauterization, coagulation, dia- 
thermy, Sturmdorf tracheloplasty, and cervical amputation. A simple 


•Read, by invitation, before tbe New York Obstetrical Society, November 8, 1932. 



654 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


erosion, ivitli ectropion, free from evidence of infection is probably- best 
treated hy means of linear striping ivitb a fine cautery tip, but if tlie in- 
terior of the cervical canal is cauterized sufficiently to destroy deeply in- 
fected glands, sloughing, secondary bleeding and extensive cicatrization 
may follow. Coagulation diathermy will destroy the infection but will 
also jeopardize the integi'ity of the portio in general, as the depth of heat 
penetration cannot be controlled. The Sturmdorf tracheloplasty has 
yielded excellent results in many cases, especially when the portio has been 
deeply and irregularly lacerated, but anesthesia and hospitalization are 
necessary, and as Wolfe’ has recentlj’’ demonstrated, islands of infected 



Rubber Insulation 



Pig. 1. — Construction ol instrument. 


glands are frequently left in the region of the internal os. Marked cystic 
degeneration, hypertrophy, or elongation of the ceiwix, especially if the 
patient is at or near the time of the menopause, are definite indications for 
partial or complete amputation. 

The procedure now knoAvn as conization was originated and developed 
to insure complete excision of the diseased endoeervix without injury to 
the underlying stroma and musculature, and with a minimum of operative 
detail and the elimination of hospitalization. Essentially, this consists of 
cutting out the core of diseased tissue by means of a fine, smooth high fre- 
quency current. An electrode for the intracervical maneui ers was de 



HYAMS: CONIZATION OF THE UTERINE CERVIX 


655 


vised and adapted to tlie normal fusiform configuration of tlie cervical 
canal and the depth of its compound racemose glands. 

The instrument was originally described and presented before the Sec- 
tion of Obstetrics and Gynecology of the New York Academy of Medicine 
in May, 1927.- In a paper read before the American Congress of Physical 
Therapy in November, 1929, 111 eases in which the instrument had been 
used, were reviewed.® A third paper was read before the New York 
Electro-Therapeutic Society in May, 1930.* 

The instrument consists of the following parts (Pig. 1) : 

1. A metal rod, two and a half inches long, and one-eighth inch in diameter ; 

2. A silicon tube one and a quarter inches long, securely attached to the proximal 
end of the metal rod; 



Niff. 2. — Schematic drawing of surgeon and patient during conization. 


3. A fine tungsten wire, attached at the metal-silicon junction, with its other end fit- 
ted into the distal extremity of the silicon tube. This wire is not straight, but describes 
an arc with its widest portion one-eighth of an inch away from the silicon tube. It con- 
forms to the spindle-shaped contour of the cervical canal. 

4. An insulating sheath of hard rubber covers the metal-silicon junction and the 
proximal half of the metal rod. 

The instrument fits into an insulated universal electrode handle which is seven and a 
lialf inches long. A connecting tip of swivel action is attached to the distal portion of 
tlie liaiidle, to provide contact with the conducting wire from the high frequency 
apparatus. 

The patient is placed and draped on the examining table in the usual manner. The 
cervix is exposed and illuminated with a bivalve speculum, fitted n-itli the Hyams light 
carrier. The vaginal fornix and cervical canal are swabbed with hydrogen peroxide to 
rid tlicm of discharge, and wiped dry. A small crystal of cocaine hydrochloride is 



656 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


placed in tlie cervical canal and allowed to dissolve, or an applicator saturated with 50 
per cent solution of cocaine is inserted into the cervical canal and loft for five minutes. 
This local anesthesia is sufficient to permit painless conization and is apparently free 
from untoward effects. An inactive, wet metal electrode about six inches square, con- 
nected to the high frequency machine, is placed on the lower abdomen and held there 
firmly by a strap or sand-bag (Pig. 2). The patient is directed to make firm compres- 
sion -ttith both hands, to create an even contact and to distract her attention. The depth 
of the cervical canal is then measured and an appropriate instrument selected. This 
active electrode is connected to the other pole of the high frequency machine by a second 
conducting ivire. The current is turned on sufficiently to provide the proper quantity 
for the operation. The instrument is held firmly in the right hand and the other hand 
steadies it. The tip of the instrument is held about one-eighth of an inch away from the 
external os, and the foot switch closed, thereby completing the electrical circuit which 
creates a spark. With the current still flowing, the silicon portion of the instrument is 
passed into the cermcal canal to the internal os, allowing the spark to cut its way 
through the tissue. The diseased mucous membrane is then coned out by rotating the 
electrode SCO degrees (Pig. 3). After releasing the foot swatch and withdrawing the 
electrode, the diseased endocervical tissue will be found adhering to the tungsten wire 
and the silicon tube, or is removed wfitli a dressing forceps, and a few drops of blood 



Fig. 3 , — Removal of the diseased endocervical tissue. 

may apj^ear in the canal. If the first core removed, fails to include all the infected 
mucous membrane, more tissue may be cut away by the reintroduction of the instru- 
ment and repetition of the process. On completion of the operation an applicator satu- 
rated tvith 2 per cent mercurochrome solution is placed in the cervical canal and left for 
several minutes. A light vaginal mercurochrome gauze packing is adequate to control 
the slight bleeding which might occur. Pour days after conization, a thin, grayish film 
■will sometimes be found in the cervical canal. The ra'w surfaces are swabbed with mer- 
curochrome. By the seventh day, the cervical canal wll be found smaller and granula- 
tion tissue appears. After two or three weeks, the cervix approximates its norrnal size, 
but a few small unhealed areas may still be emdent. Pour ■\veeks after operation, the 
eroded areas are usually completely covered with epithelium and the entire cervix looks 
healthy. Vaginal douches are inadvisable and unnecessary. 

I have practiced the described technic in 547 cases during the past five 
and one-half years, and 232 additional patients have been similarlj’’ treat- 
ed by my co-workers at the New Yoi'k Post-Graduate Hospital, making 
a total of 779 cases on which to base this presentation. We are all m 
accord that conization is not a panacea for all eases of chronic endo- 
cervieitis, and candidates must be selected with discrimination. The 
best results are observed in patients suffering from chronic endocervica 
infection with extensive glandular involvement but without complicating 
features. 



HYAIMS: CONIZATION OF THE UTERINE CERVIX 


657 


In 12 cases, it was necessary to repeat the operation after several 
months, probably because some infected glands had been left in situ at 
the original sitting. This is partially explained by the extreme caution 
exercised in our early experience. I would urge, however, that it is 
advisable for any one who employs the method to be very careful until his 
proficiency is developed. In properly selected cases, conization may be 
relied upon to cure leucorrhea and backache of endocervical origin and 
to eradicate infections of the endocervical glands. The economical fea- 
tures and simplicitj’^ of the method appeal to the patient, as general an- 
esthesia, hospitalization, and loss of occupational time are all obviated. 
The procedure is painless and does not even cause discomfort. 

Bleeding sufficient to cause anxiety or to incapacitate the patient has 
not occurred in any of the cases in which the correct technic has been 
followed. In about 2 per cent, there was slight oozing for a few days. 
The bleeding at the time of operation can always be arrested by the 
mereurochrome vaginal pack. There have been no inflammatory pelvic 
complications, as only chronic infections of the cervix have been treated. 
Conization is not advocated until after an acute inflammation has sub- 
sided and the active process has become quiescent. 

A careful, conscientious, and unbiased follow-up of our series of 779 
cases treated by conization, shows that 90 per cent have been relieved 
of their symptoms and now present a healed and apparently normal cer- 
vix. Some of these patients have been observed at frequent intervals 
for five years or more. Pregnancy occurred in 27 patients, although 
none of them had been treated with conization with the deliberate pur- 
pose of curing sterility. It is logical however, that removal of the cervi- 
cal infection should favor impregnation. None of the labors in these 
cases was undulj^ prolonged or difficult. In several, the labors were con- 
ducted by my associates, and in others, the hospital records indicated 
that the cervix dilated normally and ivithout undue laceration. One of 
my colleagues has performed conization during the early months of preg- 
nancy to relieve a profuse cervical discharge. While no untoward re- 
sults were noted, I cannot endorse this practice. The endocervix was 
coned out in a number of patients in whom the, presence of trichomonas 
vaginalis could be demonstrated, but the persistence of leucorrhea and 
trichomonas was convincing evidence of the futility of the procedure as 
a curative agent. 

Extraneous lesions to which the endocervicitis is secondary must be 
dealt udth before treating the cervix locally. The circulatory stasis inci- 
dental to a uterine retrodisplaeemcut or subinvolution sometimes gives 
rise to symptoms similar to those of endocervicitis. Under these circum- 
stances, conization will not only fail to arrest the leucorrhea and back- 
ache. but may even intensify them. When the cervicitis is only a con- 
comitant of otlier pelvic conditions, such as inflammatory involvements 
of the urogenital tract, fibromyomas, retained decidua, myometrial fibro- 



658 


AiMERICAN journal OF OBSTETRICS AND GYNECOLOGU 


sis, endometrial polyps, etc., particularly if no real infection is present, 
conization is not indicated. The fact that it was performed in such cases 
in my early experience without bad after-effects, is no criterion that 
exact diagnosis and indications for the method are not of paramount 
importance. 

Ihe instrument used must conform to the anatomical contour and 
length of the cervical canal and the histologic character of the lining 
membrane, which is one-eighth of an inch in depth and rests upon the 
basement membrane. Modifications of the Hyams electrode have been 
devised which do not duplicate the original specifications. Too much 
projection of the wire bejmnd the proximal end of the silicon tube forms 
an irregular circular loop, which in use, gouges out the tissue, cutting 
a cone equal to its diameter thi’ough the internal os and the surrounding 
structures. This results in coagulation, postoperative hemorrhage, slough, 
and severe irritation of the underlying tissue. 



Fig. 4. — -Microscopic section of cervix, pow^r magnification, showing tissue removed 

by conization. Note minimiipi amount of trauma. 

The proper instrument should be operated from a high frequency 
machine incorporating a special unit which generates a fine, smooth cut- 
ting current. This machine may be either of the gap or radio tube 
type. Some of the units made for supplying electrical energy, pro- 
duce a current so intense as to not only burn the tissues, but also to 
coagulate and even cauterize, instead of delivering a fine cutting current 
with a minimum of coagulation. Destruction of tissue with subsequent 
stenosis is not unusual under these conditions. The right current is just 
as indispensable as a perfectly designed wire electrode. Those failures 
and undesirable results which have been reported, bave been unjustifi- 
ably attributed to the method rather than the real cause : poor equipment, 
improper technic, or misapplication in unsuitable cases. A case was le- 
cently brought to my attention, which almost terminated fatally aftei 
an attempted conization with a faulty instrument and a coarse cutting 
current, in a patient ^vith an acutely anteflexed uterus. The opeiator 



HYAMS: CONIZATION OF THE UTERINE CERVIX 


659 


burned and coagulated completely through the internal os and perforated 
the lower uterine segment, passing the electrode into the peritoneal cav- 
ity. In another instance, cicatricial stenosis was unfairly blamed on coni- 
zation. Investigation disclosed that a high frequency apparatus deliv- 
ering a hard, coarse current of too high intensity was used, resulting in 
severe burning and coagulation, with subsequent stenosis. As a matter 
of fact, conization has been used successfully in relieving both partial 
and complete stenosis. In my own eases and those of my coworkers, there 
has not been a single instance of stenosis. On the contrary, the natural 





At •.« v V-:!. 


iii. 

Pig. 5. — Microscopic section of cervix, low power magnification, six months 

after conization. 








1 ? 

Fig-. 6. — Loops used for biopsy of cer\'i.':. 

reparative processes are aided and healing expedited. The muscular tis- 
sue remains intact and there is practicallj'- no scar formation (Fig. 5). 

The conization technic is particularly well adapted to securing biopsy 
specimens of tissue from the cervix, as pain and the necessity for dilata- 
tion aie a\oided. Although the standard conization electrode may be 
used, special small square and round electrodes of different sizes were 
devised for this purpose (Fig. 6). These loops are ideal for suspected 
cases of carcinoma, especially when the cervix is relatively inaccessible 
and cannot be reached with the usual instruments. The incidental heat 
and absence of trauma are of material advantage. There is little danger 






660 


a.:merican journal of obstetrics and gynecology 


of seattei'iug malignant cells into the adjacent lymphatics and secondary 
bleeding is insignificant (Fig. 7). 

In closing, I wish to emphasize that the technic can be utilized in the 
gynecologist's office, that tissues can be removed to any desired extent, 
and the procedure may be repeated if necessary to excise the diseased 



area completely. With correct equipment, the cutting proceeds smoothly, 
the tissues are divided accurately, and the generated heat assures asepsis. 
Most important of all, however, is the dictum that the patient must always 
be adapted to the procedure, and not the procedure to the patient. 


REFERENCES 

Byams, Mortimer N.; N. Y. State J. Med. 28: 64G, 1^28. 58 ^.' 268 

Arch. Physical Therapy 11: 171, 1930. ’ 

1930. TTolfc, Samuel A.; Am. Obst. & Gynec. 24: 8(, 193-. 

78 East Seventy-Ninth Street. 

ABSTRACT OF DISCUSSION 

DR. WALTER T. DANNREUTHER.— I desire to verify the statements that 
Dr. Hyams has made and to emphasize a few of the importan poin s. “ ' 
have now accumulated a tremendous number of these patients in our c inic, 
have seen the after-results two, three, four, or five 
only add that they are all that the pictures show them to be. Hou i ’ 
is iise to reiterate that this method is not applicable to al cases 
indiscriminately, and Dr. Hyams is to be conin, ended in that he 
fact. As he said, in the case of a severe deep laceration vith ^ 

where perhaps a primary pyogenic infecHon ^,tter amputated 

■woman is at or near the menopause, ^^e still fee . , . ^Tl n voiiue- irirh 

or removed as part of a total liysterectomy. Again, a simp e ero ^est 

o, i„ . polvi. 

treated with linear cautery striping. I firnilj Sturmdorf 

of extirpation of the diseased endocervix are far 2;crd«il aiM does not 

traoheloplasty ; we get better results, it is a inuc i niethod was demon- 

involve hospitalization. Of course, „pon for the prolapse, and 

strated in the motion picture were afteruaids opeia i 



HYAMS: CONIZATION OF THE UTERINE CERVIX 


661 


conization was carried out in these two cases only to facilitate the demonstration of 
the details of the technic. 

DE. ISIDOE C. BUBIN. — was interested in the biopsies done six or eight months 
after the initial treatment. After allj we have to think further than the immediate 
result with this treatment. We can accept the doctor’s statement that the diseased 
endocervix is extirpated by this method, that it is a bloodless, painless, ambulatory 
method and, I believe, the most ingenious so far devised. 

I would like to ask Dr. Hyanis if he has seen sections of the whole cervix. The 
sections that we saw tonight showed stratification of the epitlielium lining the cervical 
canal; but these were from biopsies. This method would appear to be applicable to 
patients approaching the menopause or thereafter. But from what I have seen, both 
of his work and in the short experience I have had with his method, it no longer 
appears necessary to amputate the cervix in the case of multipara for erosions, 
lacerations, and eversions. The cervix can be cleaned up, the canal eventually becomes 
epidermized and a satisfactory healing takes place. I should hesitate however to 
subject nulliparous women who are desirous to bear children to this radical treatment 
for the relief of a leucorrhea or even endocervicitis. Dr. Hyams mentioned the fact 
that in some 20 odd cases pregnancy has followed the treatment and no dystocia was 
noticed at the time of labor. It seems to me it would be important to know how 
many of his 500 odd cases were nulliparous women who, though anxious to have 
children, nevertheless did not become pregnant. 

The question that concerns me most is tlmt of stenosis, which Dr. Hyams says has 
been excluded in his experience. Until one acquires such an experience one may pro- 
duce a permanent barrier against conception. 

DB. HYAMS (closing). — The greatest number of patients treated have had one 
or more children. In a previous summarj’, we concluded that chronic endocervicitis 
occurred more frequently after abortion, miscarriage and childbirth, rather than fol- 
lowing gonorrheal infection. 

There are many causes for sterility. Occasionally a profuse cervical discharge may 
prevent or make impregnation difficult. Conization is performed to relieve the dis- 
charge and not for relief of the sterile condition. It is logic.al to assume that removal 
of the infection should favor impregnation and of the 27 patients who became preg- 
nant following this modality, none was treated primarily for sterility. To cite a 
specific instance: Mrs. S. presented herself in 1927 complaining of a profuse vaginal 
discharge and also sterility. Conization was done to eradicate the chronic endocer- 
vicitis present. Shortly after, she became pregnant, and in the early part of 1928 
her accoucliemcnt took place at the Fordhain Hospital. The hospital records revealed 
an uneventful delivery of a normal child with no dystocia or undue laceration of the 
cervix. In another instance, a patient with chronic endocervicitis became pregnant 
following conization of the cervix. One of my associates at the New York Post-Grad- 
uate Hospital had her registered on his service at the Long Island College Hospital 
where lie, personally, could follow lier parturition. He reported a normal delivery 
and stated that no one would ever know that anything had been done to the cervix. 
In no instance, to my knowledge, has there been dystocia or a prolongation of the 
labor or excessive laceration of the cervix from sear tissue as a result of the previous 
treatment. 

The treatment of chronic endocervicitis in the nulliparous woman is sometimes 
very difficult. Linear striping of the cndocervical tissue with a fine cautery tip often 
gi\cs excellent results. Dr. Dannreuther has emphasized the point that this method 
has not been discarded by us. 

It is our purpose to make a correct diagnosis and select the .appropriate treatment. 
The best results are based on eradication of infection with a minimum trauma to the 
cervix, and this we believe is best achieved by the proper use of conization. 



THE MECHANISM AND MANAGEMENT OP THE THIRD STAGE 

OP LABORS' 

Murray L. Brandt, M.D., New York, N. Y. 

T) AUDELOCQUE, recogniziug the normal processes of the third stage 
J-' of labor, is credited with being the first to distinguish between sep- 
aration and expulsion of the placenta. As early as 1799 Osiander talivs 
of “expression” of the placenta and in 1820 he described a maneuver 
resembling the Crede Method, assisting this with traction on the umbili- 
cal cord. However, little attention was given to this period of labor until 
Crede presented his own mode of management in 1853. This became 
popular immediately and remained the accepted manner of procedure 
until Alilfeld, Dohrn and others began their attacks on the Crede manipu- 
lation, advising an entirely opijosite method of treatment. For many 
years this controversj’- raged and although compromises have been offered, 
the final solution of the problem has not yet been reached. 

As the child is being expelled, in a normal labor, the size of the uterus 
diminishes partlj’’ as a result of muscular tone and partly due to uterine 
muscle contraction. As a result of this change the veins in the muscle 
layer of the uterus are compressed so that maternal blood in the placenta 
can not escape from the uterus. At the same time the reduction in size 
of the uterine cavity has squeezed the placenta so that the blood in the 
intervillous spaces is forced into the veins of the decidua. We therefore 
have a layer of overdistended veins in the decidua spongiosa, lying be- 
tween a firmly contracted uterine Avail and a more or less solidly com- 
pressed placenta. As a result of this vise-like compression, the congested 
venous sinuses burst aud the extraA^asated blood under tension causes 
tearing of the very fine septa of the spongiosa, thereby detaching the 
placenta from its uterine site. 

For this normal mechanism to occur, the factors mentioned above, i. e. 
contracted uterine Avail and compressed compact placenta, must be pres- 
ent. If either of these is absent, separation does not folloAV a normal 
course. If the uterus does not contract as the child is being horn, then 
separation does not occur until an after-pain has set in, causing reduc- 
tion in the size of the uterine cavity as well as contraction of the muscu- 
lar Avail of the uterus. On the other hand, if the placenta is thinned out 
and covers an area much larger than normal, there does not dcA'^elop the 
usual counter resisting mass of compressed compact placenta, hence 
separation is delayed. 

As the separated placenta is detached from its uterine site, it folds 
on itself, but it is held in the uterine cavity because of the firm attach- 

*Head, by invitation, at a meeting of the New York Obstetrical Society, December 



BRANDT: THIRD STAGE OF LABOR 


663 


ment of the membi'anes. If tlie wterme contraction, tliat lias separated 
the placenta, is strong, the placenta may be expelled into the lower uterine 
segment and upper “Vagina, the placenta acting as a foreign body. If 
pituitrin is given at the end of the second stage of labor, this mechanism 
is the rule. When this occurs, the retroplaeental hematoma does not form 
and could have no function. 

• If however, after placental detachment, with the membranes still firmly 
adherent, the separating pain is not strong enough to force the placenta 
out of the uterine cavity, bleeding both from the intervillous spaces of 
the placenta and from maternal sinuses takes place during the following 
uterine relaxation. 

The subsequent uterine contraction acting on the increased bulk as 
on an hydraulic wedge forces the placenta down into the lower segment, 
peeling the membranes off the uterine wall at the same time. Manipula- 
tion of the uterus at this time may detach the membranes at one point 
so tliat the retroplaeental blood escapes without completely detaching 
the membranes at the placental border, resulting in retention of the 
placenta, with increased bleeding. 

In a series of 30 cases in which we injected the umbilical vein with a 
solution of sodium iodide, immediately after the birth of the child we 

• found the placenta detached and folded on itself in every case lying in 
the lower segment of the uterus. X-rays were made within three min- 
utes of the delivery of the baby. We used an amount of solution equal 
to the quantity of blood that flowed from the severed cord, an average 
of 50 c.e. 

A century ago, it was the recognized procedure of experienced 
accoucheurs to deliver the placenta by traction on the umbilical cord, 
after separation, as corroborated by vaginal examination, had been estab- 
lished. Although Crede in 1853 agreed that in the hands of accomplished 
obstetricians, this was a satisfactory method, he showed that complica- 
tions were frequently encountered by the unskilled. To prevent these 
and to obviate the necessity for vaginal interference, he devised a 
method of manual compression of the uterus at the height of contraction, 
expressing the placenta thereby. In his early work, he waited fifteen to 
thirty minutes for uterine contractions to occur, but in 1861 he concluded 
tliat it was better to express the placenta as soon as possible after the 
birtli of the child. This mode of delivei'y still has its followers today. 

Ahlfeld working with Crede found that the same complications that 
liis teacher had condemned in the eoi'd traction method, occurred not 
infrequently when the expression maneuver was performed by incompe- 
tent midwivos. He therefore postulated his famous doctrine of “Hands 
off the uterus,” the complete antithesis of Credo’s teachings. Alilfeld 
stated that his expectant treatment provided time for the development 
of a retroplaeental hematoma Avhich Avould completely separate the pla- 
centa. act as a tampon alloAving thrombosis of the vessels of the placental 



664 


AaiERICAN JOURNAL OF OBSTETRICS AND - GYNECOLOGY 

site and prevent tlie entrance into the uterus, oi bacteria from the vaginal 
canal. 

We know today that his premises were wrong, that the retroplaeental 
iiematoma is not necessary for idaeental separation, that thrombosis, of 
the vessels of the placental site is usually considered patholog’ic and 
that the empty parturient canal is the best prophylactic against puerperal 
infection. 

When it was found that indefinite waiting’ for spontaneous exijulsion 
allowed an excessive loss of blood and that only 14 per cent of cases 
delivered the placenta without some assistance, the method was modified 
by arbitrarily limiting tlie period of expectancy and then applying the 
Crede expression. 

Many obstetricians, especially Americans believe that in these methods 
there is an unnecessary waste of time and that the placenta can be safely 
delivered as soon as it is definitelj’- shown tliat it has completely separated. 
The establishment of placental separation in this method precludes the 
'dangers inherent in Crede ’s original technic. The plan of treatment is 
watchful control of the uterus with expression when signs of descent 
are present. 

However, all methods of compressing or pushing the uterus down- 
wards towards the pelvic cavity are unnatural because not only do they 
contuse and bruise the uterine wall, but they cause a passive congestion 
of the uterus which may produce bleeding during the subsequent relaxa- 
•tion. 

It may be impossible to express the separated placenta from the uterine 
cavity, by any of the usual methods because of closure of the cervix. 
The only treatment required is waiting until this contraction has relaxed, 
and repeating the necessary maneuver to cause expulsion of the placenta. 
This is not infrequent especially after the use of pituitary extract. 

Should the deiaj’^ be due to failure of placental separation, three con- 
ditions must be differentiated. In the first, the placenta remains adherent 
because of lack of uterine contraction as is found in cases of overdis- 
tended uteri, in excessively long labors and after prolonged and deep 
anesthesia, In the second class are cases where the placenta covers a 
large surface area and is very thin, hence it does not offer sufScient bulk 
for the uterus to contract upon. In the third group are cases of pathologic 
conditions of placenta and decidua. 

In the first group, methods of exciting uterine contraction are indi- 
cated after allowing some time to elapse for the uterus to regain its 
normal muscle tone. Here especially is pituitary extract of value. The 
routine injection of posterior pituitary extract, immediately after the 
completion of the second stage of labor, has found many advocates uho 
report excellent results from its use. However, no uterine contraction 
caused by artificial means is similar to normal spontaneous contraction. 
The uterus is always in a state of tone and is never completely relaxed. 



BRANDT: THIRD STAGE OF l.ABOR 


665 


The normal lessening of tone following a normal spontaneous contraction 
is of lesser degree than the marked decrease of tone following a strong 
artificially induced uterine contraction. Secondary bleeding is more 
common and more profuse following such artificial contraction. 

In the second group, th6 placenta failing to separate because of exces- 
sive thinness of its structure, offers an idnal condition for the use of the 
Gabaston method of injecting a solution into the umbilical vessels, 
increasing the weight and volume of the placenta. This procedure has 
received a great deal of trial and is- in constant use in many of the large 
clinics. 

If tile Gabaston procedure fails to separate the placenta, manual ex- 
ploration of the uterine cavity is the next logical step, to determine 
whether the placenta can be easily peeled off the' uterine wall. If the 
decidua spongiosa is normally developed, a plane of cleavage will readily 
be found and the placenta can be removed in toto. 

When true placenta accreta exists, no line of cleavage can 'be secured, 
for the spongiosa is either scanty or absent and the villi are anchored 
in the uterine muscle. In such eases complete removal is fraught with 
great danger of infection and hj’^sterectomy is of life saving value. 

Dickinson in 1899 had advised lifting the uterus high out of the pelvis 
by abdominal manipulation, in order to control postpartum hemorrhage. 
Fuchs in 1919 advised pushing the uterus upAvard to aid separation of 
the membranes. - 

In a recent very interesting and complete discussion of this subject. 
Smith describes the Dickinson-Pomeroj’' technic of management of the 
third stage. This method has given excellent results Avith an extremely 
loAA- incidence of severe postpartum hemorrhage. Having used this up- 
Avard lifting of the uterus for several years in controlling postpartum 
bleeding, I decided to use this same maneuver to aid the delivery of the 
separated placenta. 

After the birth of the baby, attention is first directed to the care of 
the child. The perineum is cleansed and inspected to determine the neces- 
sity of repair and preparations made accordingly. During this time there 
is no abdominal manipulation. Five to ten minutes haAm noAv elapsed 
from the time of the birth of the baby and the separated placenta should 
be in the ceiwix and upper A^agina. 

An artery clamp is placed on the umbilical cord close to the vulva 
and held in one hand Avhile the other hand is placed on the abdomen of 
the mother, in such a manner that the thumb lies parallel to the SA^mphy- 
sis and palm and fingers approximate the surface of the uterine body. 
Holding the umbilical cord taut, a gentle upAvard push is made on the 
loAvcr segment by the hand on the abdomen, AA-ithout attempting to gra.sp 
the uterus. If the placenta lies in the dilated ceiwical canal or upper 
vagina, tlie uterus Avill rise upAvard and there Avill be but slight tension 
on the cord held in tlie artery clamp. If it rises, a further series of 



666 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


gentle pushes eauses the uterus to ascend towards the diaphragm while 
the placenta remains in the vagina. It is usually sufficient to raise the 
uterus to a level where the umbilicus is about at the middle of the uterine 
body. Frequently in performing this maneuver, one feels the membranes 
peeling off the lower uterine segment. 

When the first upward push causes tension on the umbilical cord, no 
further attempt is made for several minutes. Persistence of upward pres- 
sure when tension is felt, is to be avoided, for it is similar in effect to 
traction on the cord. This failure of the uterus to rise when pushed, 
results most frequently from closure of the cervix holding the placenta, 
and one must wait for it to relax. 

Wlien the uterus has risen high in the abdomen, the placenta lying 
in the vagina is expelled by gentle doAvnward pressure just above the 
symphysis. The uterus is held high, between the hands of an assistant 
for fifteen minutes, during which time the perineal repair is accom- 
plished. 

In this method of managing the third stage of labor, the uterus is not 
massaged. or squeezed and is therefore allowed to contract normallj'- while 
the usual relaxations of the musculature are not so marked as those 
occurring in artificially stimulated uteri. The empty uterus contracts 
readilj'. The upward pull on the uterus causes stretching and narrow- 
ing of the vessels supplying blood to the uterus producing an anemia of 
its musculature, aiding firm contraction. 

In a series of 800 obstetric cases in which this method of assisting the 
delivery of the placenta, was eai’ried out, there was an average blood 
loss of 61/^ ounces. In the 415 primiparas the loss was slightly higher 
than in the multqi'aras, averaging 7 ounces. There were 138 forceps de- 
liveries, 113 of which were in primipara with an average loss of 13 
ounces of blood. There were 10 cases in which bleeding was more thaui/ 
normal; 5 patients lost 22 ounces; 2 patients, 24 ounces; 1 patient, 34 
ounces ; and another of 36 ounces, while one patient had a severe bleed- 
ing with a loss of 60 ounces of blood. This last case was one of tAvin preg- 
nancy in uffiich the placenta separated after a delay of thirty minutes 
and was expelled in the usual manner. The patient bled profuselj'’ as 
a result of uterine atony. The uterine muscle did not seem to respond 
to pituitrin injections and intrauterine packing rvas finally successful 
in controlling the hemorrhage. The patient made an uneA'^entful recov- 
ery. The other 9 cases of abnormal bleeding occurred in patients delir^- 
ered by forceps. 

The average duration of the third stage in this series of cases was 
eight minutes. There Avere three cases of delayed third stage. The first 
Avas the ease of postpartum hemorrhage folloAAdng delivery of twins men- 
tioned above; the second case, after AAmiting one hour, no signs of sep- 
aration having occurred, intrauterine exploration Avas done. The pla-^ 
centa was found to cover almost the entire surface of the uterus and 



DEAN: INJURY OF URINARY BLADDER 


667 


was very thin. A plane of cleavage was easily found and the placenta 
peeled off the nterns without any difficulty. This placenta was unusually 
large being 101/2 inches in diameter and only one-half inch in thickness. 
Bleeding in this case was normal and the puerperium was uneventful. 
In the third case there was a bi-lobed placenta, each part being as large 
as a normal size placenta and connected together by one large vessel. 
In this case the placenta had separated but could not he expelled because 
of its unusual bulk. After attempting the lifting of the uterus method 
intermittently for thirty minutes, vaginal examination revealed the lower 
edge of the placenta in the cervix. A powerful Crede manipulation was 
required to expel this double placenta. 

There was no death in this series. No injury of the cord, placenta, or 
membranes occurred in any ease. Although the cord must he held taut, 
traction must be avoided. If the placenta has descended and is not held 
b}"- the closed cervix, but slight tension null be felt as the uterus, rises 
easily. The upward push on the lower segment and body of the uterus 
does not interfere with the normal course of placental descent though 
the manipulation may have been performed before the placenta was in 
the cervix. 

, This method of management of the third stage is presented for con- 
sideration with the hope that it may be given further trial. 

2021 Grand Concourse. 


INJURY OR THE URINARY BLADDER FOLLOWING 
IRRADIATION OF THE UTERUS* 

Archie L. Dean, Jr., New York, N. Y. 

(From the Department of Urology, Memorial Hospital) 

I N 1927 the writer described ulceration of the bladder which occasionally 
followed applications of radium to the uterus. That paper was based 
upon tlic study of three patients. Since 1927, 47 women have been ex- 
amined and treated for pathologic conditions of the bladder caused by ir- 
radiation of the uterus. In the earlier group, radium alone had been used, 
and in each case the bladder lesion was an ulcer. In the larger, more re- 
cent series, the majority of the patients were treated with the roentgen 
rays in addition to radium, and the bladder findings varied considerably 
although ulceration predominated. Therefore in the introduction to this 
study, , we must attribute a certain etiologic importance to the i-oentgen 
rays, though it is a minor one, and recognize that the bladder injury fol- 
lowing uterine irradiation may be of different degrees of severity. 

Irradiation has become an approved method of treating several uterine 
diseases, benign as well as malignant. Facilities for the use of both radium 

13 . meeting of the New York Obstetrical Society, December 



6G8 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


and the roentgen rays are almost universal. Even when these agents arc 
employed conservatively by skilled operators a certain nnmber of women 
subsequently develop injury of the bladder. This complication may be 
difficult to diagnose and treat. The patient may suffer great pain and the 
lesion, unless arrested, may cause serious injury or even death. For these 
reasons urologists and gjmecologists should familiarize themselves with 
the condition. 


Table I 


DISEASE 

XUAIBER OF 

CASES TREATED 

NUMBER WITH 

BLADDER INJURY 

PER CENT WITH 
BLADDER INJURY 

Carcinoma of 
eerviXj primary 

1474 

31 

2.10 

Carcinoma of 
cervix, recurrent 

S2 

6 

7.31 

Carcinoma of 
cervix, postopr. 
prophylactic 

36 

1 

2.7 

Carcinoma of 
corpus 

131 

3 

1.92 

Carcinoma of 
ovary 

43 

1 

2.3 

Fibromyoma 

uteri 

798 

3 

0.38 

Nonmalignant 
myopathic bleeding 

4.37 

3 

O.Oo 


It is difficult to learn the proportion of patients who receive bladder in- 
jury from uterine irradiation because the patient must live several years 
after irradiation before the injury appears. Uufoi’tunately a substantial 
number of women do not survive so long. It is important to note that all 
of the patients but one of this series were free from symptoms or signs of 
the primaiy uterine disease at the time bladder injury was discovered. 

ETIOLOGY 

Bladder injury as a consequence of irradiation of the uterus is not pri- 
marily the fault of unskilled operators. In fact each patient in this series 
was treated by a gjmecologist of experience. These sui'geons were aware 
of possible bladder complications and took all known precautionary 
measures. 

Nothing was found in the general examinations of these patients which 
might suggest that they were abnormally sensitive to radiation. Pelvic 
examinations did not show that radium placed in the cervical canal or 
uterine cavity would be unusually close to the bladder. 

Bladder injury may follow irradiation of any uterine disease. This 


series included the following : 



Carcinoma of cervix 
Primary early 

Primary borderline 
Primary advanced 
Postoperative recurrent 
Postradiation recurrent 

10 cases 

6 

15 

3 

2 

Postoperative prophylactic 
Carcinoma of corpus 
Carcinoma of ovary 
Fibromyoma uteri 

Clironic endometritis 

Chronic endocervicitis 

1 case 
3 

1 

3 

1 

2 




dkan: injury of urinary bladder 


669 


By comparison with all of the women treated in the same time interval, 
we find that the figures shown above represent the percentages indicated in 
Table I. 

Irradiation of uterine tumors has largely become standardized, iilinor 
variations in management may occur because of personal preference, dif- 
ferences in the applicators available, or peculiarities of individual tumors. 
Healy has described the methods used at the Memorial Hospital. His ap- 
plicators are listed below together with the doses usually prescribed. If 
we assume that the base of the bladder is an average distance of 2.5 cm. 
from the source of radiation, it is not difficult to compute the number of 
skin erythemas which the bladder receives from radium. Penetration of 
the roentgen rays to the bladder is indicated as well. 


Table II 


SOURCE OF RADIATION 

USUAL DOSE S. I 

i. D. RECEIVED BY BLADDER 

Pelvic Cycle H-V roentgen rays 4 Exposures 

(2 ant. 2 post.) 

700-800 r each 

1.2 

Vaginal applicator 

1,000 me. hr. 

to rt. It. and center pelvis 
(total 3,000 me. hr.) 

3 

Cervic tandem 

3,000 me. hr. 

3 

Fibroid tandem 

3,000 me. hr. 

3 

Stem and base applicator 

3,000 me. hr. 

3 


When gold seeds are used to furnish interstitial irradiation, the bladder 
base receives approximately 1 S. E. D. from each i me. or 528 me. hr. 

At the time the earliest bladder injuries appeared there was specula- 
tion as to which type of uterine treatment was responsible. From the 
figures shown above, it is evident that the radium applicators and gold 
seeds produce the greatest bladder changes and the roentgen rays are of 
less importance. Generally speaking, for each 1,000 me. hr. delivered to 
the cervical canal or uterine cavity by any of the usual radon applicators 
the bladder wall receives 1 S. E. D. If gold seeds are used, the bladder re- 
ceives 1 S. E. D. from each 500 me. hr. 

There was wide variation in the amount of radiation given the patients 
in this series. The smallest dose was 1284 me. hr. administered in the 
form of a fibroid tandem for fibromyoma uteri. Prom this treatment the 
bladder received a trifle less than 1% S. E. D. The largest doses were 
given to four patients who were treated with several forms of radon appli- 
cators and the high voltage roentgen rays. In these eases the bladder re- 
ceived approximately 8 S. B. D. 

In the irradiation of serious diseases, especially radioresistant cancer, 
comparatively heavy doses must be given. Peculiarities of the individual 
case sometimes require that the treatment be repeated or that an unusually 
large proportion of the dose be in the form of gold seeds. It is natural that 
a higher percentage of these patients should develop bladder complica- 




670 


AJIERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


tioDS. On the other hand, occasionally a woman receives relatively light 
irradiation for a comparatively insignificant disease and subsequently 
presents painful bladder symptoms. These cases give the gynecologist 
much embarrassment. The writer, who was not present when these pa- 
tients were treated, finds it impossible to explain such an occurrence. 
Even the operators, who have frankly gone over each step in their technic, 
have been at a loss for an adequate explanation. 

It would be of interest to know Avhether bladder in.iuries are more fre- 
quent after the treatment of advanced or early primary cervical cancers. 
A clew as to the cause of the injury might be obtained because the advanced 
tumor is bulky and infected, while the early growth is smaller and less in- 
fected. Unfortunately our data are too scant. 

PATHOLOGY 

There are three well recognized radiation reactions. They will he de- 
scribed as they appear on the skin. Within about twenty-four hours of a 
therapeutic dose there is a blush or erythema. This is probably a reaction 
to irritation such as follows the application of a mild mustard plaster. It 
is not a speeifie radiation effect. 

At the end of about a month, if an average dose has been given, an eryth- 
ema appears which gi'adualb’’ turns tan and then brown. Slight itching 
may accompany the crjdhema. This is a specific radiation effect and is 
called the secondary erythema. It is thought to be caused by a temporarjL 
localized vasomotor paralysis. If an unusually strong dose of radiation 
has been applied, the secondary erythema will appear sooner and maj’' 
progress to tissue destruction. In this series four patients suffered pain- 
ful bladder sjunptoms at the time the secondaiy reaction Avas due. In- 
spection of these bladders showed conditions ranging from modei’ate con- 
gestign to acute inflammation ivith fibrinous exudate. No ulceration was 
present. The reactions ivere limited to the postei’ior bladder base. Three 
of these patients later dei'eloped other radiation injuries of the bladder, 
the fourth has not as yet. 

The most important destructii^e effect of therapeutic doses of radiation 
is the tertiai’y radiation reaction. It rvas formerlj’' called a delayed radium 
burn. Like the secondary eiythema, it is a specific radiation change. The 
lesion is the result of obliterative endarteritis and requires a considerable 
amount of time for its production. The bladder injuz’ies considered in 
this paper are manifestations of this condition. 

It is rare for the tertiary radiation reaction to appear earlier than a 
year after treatment. It may not reveal itself for more than twelve years. 
The earliest appearance in this sei'ies was ten months, the latest was 114 
months, or nine years, six months. The average time of appearance in 46 
patients was thirty months, or two yeai*s, six months after irradiation. 

The condition within the bladder closely resembles that seen on the 
skin. There may be a white, aAmscular central area surrounded by a zone 
of dilated blood vessels. If the center breaks down an ulcer is formed. 



DEAN: INJURY OF URINARY BLADDER 


671 


Whether the frequent movements of the bladder are conducive to ulcera- 
tion it is difficult to state. At any rate de&iite ulcers were found in the 
bladders of 71 per cent of the patients of this series. In conjunction with 
ulceration in the bladder there was always infection. Practically all of 
the ulcers were covered with calcareous deposits. Histologic examination 
showed gi’anulation tissue and various degrees of inflammation. In gen- 
eral, the microscopic picture was that of chronic cystitis. 

SYMPTOMATOLOGY 

The onset of symptoms usually is sudden with no premonitory sensa- 
tions. Practically all of these women were performing their accustomed 
duties when bladder distress began. The initial sjunptom was frequency 
in 70 per cent of the cases, hematuria in 18 per cent, and dysuria 
in 12 per cent. To the first symptom was almost immediately added one 
or both of the other sjunptoms. At some time dysuria was present in 87 
per cent of the eases, frequency in 82 per cent, and hematuria in 45 per 
cent. The usual train of s 5 ’-mptoms was a sudden attack of urinary 
frequency accompanied or soon followed by dysuria, with hematuria ob- 
served by about half of the patients. 

The women suffer acutely. Urination may occur every few minutes, al- 
though it is more likelj’- to be at the rate of every hour or two both day and 
night. Dysuria may be intense. It is usually described as burning in 
character, and terminal. Hematuria varies from a faint red urine to sud- 
den, uncontrollable hemorrhage with a fatal outcome. We do not know of 
a ease of serious hemorrhage occurring as an initial symptom, but two of 
our patients while under treatment bled to death in their homes before 
help could arrive while a third was barely saved by an emergency opera- 
tion and three blood transfusions. 

DIAGNOSIS 

It is essential to make the correct diagnosis because inappropriate treat- 
ment will be followed by disastrous results. Diagnosis is comparatively 
easy if the possibility of the condition is kept in mind. 

In most eases many months have elapsed since the attention of the pa- 
tient has been directed to her pelvic organs. Since the new symptoms are 
so obviously from a different source, the bladder, the patient almost never 
associates her former treatment with her present illness. As a result she 
rarely voirmteers information concerning previous irradiation. Nor does 
the skin of the lower abdomen preserve its pigmentation for so long a time 
and thus furnish a clew. When any woman complains of urinary fre- 
quency, dysuria, or hematuria, she must be asked specifically if she has 
ever been treated with irradiation for any disease of the uterus. If an- 
swered in the affirmative, the examiner should suspect a radiation injury 
of the bladder. Not infrequently bladder symptoms appear while the pa- 
tient is under the care of the gynecologist who treated her for uterine can- 
cer. Naturally he is fearful of a direct extension of that disease to the 



672 


AJIERICAN JOURKAL OF OBSTETRICS AND GYNECOLOGY 


bladder, and since such a condition may be similar in appearance to radia- 
tion injury, an incorrect diagnosis may be made. 

The cj’Stoscopic pictni'c of a radiation injury of the bladder frequently 
is indistinguishable from either primary or secondary cancer. With pa- 
tients of the cancer age presenting the symptoms of frequency, dysuria, 
and hematuria, the similarity is complete. 

A careful vaginal examination should be performed first. With radia- 
tion injury palpable induration of the bladder base is rare. This is im- 
portant because even when one finds an extensive ulcerating lesion of the 
bladder base simulating newgrovdh, one may be almost certain, if palpable 
induration is lacking, that one is dealing with radiation injury rather than 
bladder carcinoma. 

In these eases passage of the cystoscope is not excessively painful with- 
out anesthesia. The urine is more or less cloudy with pus. Mucous and 
small blood clots in an amber urine are frequent findings, or the specimen 
may be frankly discolored with blood. The reaction of the urine is almost 
always alkaline. The bladder capacity varies with the size of the ulcer 
and the amount of infection present. A radiation ulcer is always located 
in the posterior third of the bladder base, and almost always in the mid- 
line. Unusually large ulcers have been seen extending upward on the pos- 
terior wall, but I have never found involvement of the trigone, anterior 
wall, lateral walls, or vault. The ulcers are single, circular or rounded, and 
vary in size from 5 mm. to 5 cm. in diameter. The surface is covered with 
white or light gray slough. Usually this is impregnated with calcareous 
deposits. Before healing begins the slough separates from the ulcer with 
difficulty and leaves a bleeding surface. Surrounding the ulcer there is a 
red zone of intense inflammation. Not infrequently bullous edema is pres- 
ent. This may be mistaken for papillary carcinoma. 

Four per cent of our patients showed no ulcer but in the posterior third 
of the bladder base there was acute inflammation with deep red spots of 
punctate hemorrhage. 

Twenty-five per cent of the patients showed a round, white area in the 
posterior bladder base. This usually was about 1 cm. in diameter. It 
marked the center of a reddened area of vaiying size. In these cases there 
was no visible break in the surface of the mucous membrane. These pa- 
tients never had hematuria. In several cases the central avascular portion 
subsequently broke down to form an ulcer. When this oceuiT-ed hematuria 
was noted. 

In all cases a biopsy should be performed. A cystoscope rongeur is sat- 
isfactory for this purpose. The specimen is I’emoved fi’om beneath the 
slough, or, if no ulcer is present, it is taken from the congested zone sur- 
rounding the white center. Sometimes the picture resembles carcinoma so 
closely that several pieces of tissue are necessary for histologic study. ^ No 
woman with ulceration of the bladder base who previously had received 
irradiation for uterine disease should be treated for bladder cancer until 
the diagnosis has been established by microscopic study. 



DEAN: INJURY OF tlKlNARY BLADDER 


673 


PROGNOSIS, COi'IPLICATIONS AND SEQUELAE 

In general the prognosis for ultimate recovery is good. If the lesion has 
not reached the ulcerative stage, symptoms may be relieved in two weeks. 
They may disappear within a month. When ulceration is extensive prog- 
nosis must he guarded. In these eases regular treatment must be contin- 
ued for many months. A vesicovaginal fistula may form. Sudden hemor- 
rhage may cause death. The patient may become a morphine addict in her 
attempt to escape intense pain. Suffering may lower the woman's re- 
sistance and intercurrent disease may prove fatal. No ascending renal in- 
fections have been found in spite of marked cystitis and bladder tenesmus. 
Probably this can be explained by the fact that obstruction is not present 
at the bladder outlet. After the lesion has healed, recovery seems to be 
complete. Cystoseopic examination shows telangiectasis occupying the 
site of the former ulcer and the zone of inflammation. ' No permanent ill- 
effects have been noted as yet and no secondaiy breaking down has been 
seen. 

Prognosis is especially grave when it has been necessary to give addi- 
tional irradiation after a radiation injury has appeared. In these eases 
bladder damage progressed rapidly to a serious degree. 

PROPHYLAXIS 

The problem of curing the uterine disease is of paramount importance, 
but it should be accomplished with the smallest amount of irradiation. The 
bladder should be protected by packing or some other type of shielding. 
In recent years the dose of radiation for uterine tumors has been diminished 
at the Memorial Hospital and the end results have been just as good. 
Formerly uterine irradiation furnished 7-8 S. E. D. to the bladder, at pres- 
ent the average is about 5 S. E. D. Even with this reduction there prob- 
ably will be a certain number of bladder injuries because 57 per cent of 
the bladders of this series received 5 S. E. H. or less. 

Infection is another factor of importance in the production of complica- 
tions after irradiation. How large a part it plays in the bladder when ir- 
radiation is used in the uterus is not well known. At any rate, no measure 
for promoting asepsis should be overlooked. 

TREATMENT 

The management of this distressing condition should be based upon 
perseverance in the face of many discouragements. In some eases treat- 
ment extends over many months with the patient in constant pain. Under 
such circumstances every supportive measure, even blood transfusions, 
must be utilized to maintain the woman's strength and morale. In gen- 
eral, treatment is symptomatic. The principal indications are to relieve 
pain and overcome infection within the bladder. 

Pain can be relieved in most eases with Tr. Hyoscyamus, 4 c.c. in water 
every four hours. If this is unsuccessful, codeine is given by mouth. 
Whenever possible morphine should be avoided. Alkalies such as sodium 



674 


AaiERIGAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


or potassium citrate are helpful and are prescribed in all cases in which 
there is no ulceration. With ulcers and slough, phosphatic deposits grow 
rapidly in alkaline urine. Heat is soothing whether furnished hy electx’ie 
pads or sitz baths. Exercise must be curtailed. In more aggravated eases 
the patient must be kept in bed. 

Although a number of remedies have been used to overcome infection, 
none have been satisfactory. We have not been encouraged by the use 
of any urinary antiseptics administered by mouth. It is helpful if the pa- 
tient will maintain a high fluid intake, but sensitive bladders are intolerant. 
The urine should be made acid and this is difficult when phosphatic in- 
crustations cover extensive ulcers. Perhaps we have had the gi-eatest suc- 
cess with dilute phosphoric acid, 2-4 e.c. in water after each meal. 

Lavage and instillations of the bladder have been the most valuable 
measures in our experience. Por lavage, 1-2 per cent of phosphoric acid 
or one part of hydrogen peroxide in three parts of boric acid may be used. 
Lavage is followed, in the more acute eases with an instillation of 15 c.c. 
10 per cent argjn-ol. As the patient becomes more tolerant, the strength 
of the phosphoric acid may be increased to 5 per cent, and instillations of 
15 c.c. of 2 per cent mercurochrome No. 220 may be substituted for the 
argjn'ol. The best results are obtained from dailj’^ treatments. Ambula- 
tory patients in clinics receive two or three treatments a week. 

If the calcareous deposits arc removed mechanically great gentleness 
is required. The cystoscopic rongeur or forceps are satisfactory for this 
purpose. Serious hemorrhage may be started if slough is removed before 
a certain amount of healing has taken place. If slough separates en masse 
it may obstruct the urethra. This gives rise to characteristic symptoms 
easily relieved hy the eystoseope and forceps. 

Treatment should be continued without interruption until healing is 
complete. Then the urine should be kept taintly acid and the patient 
should report for a follow-up examination every few months. 

SUMMARY 

Forty-seven women have been examined and treated for injuries of the 
bladder after irradiation of the uterus. Both radium and the roentgen 
rays had been used, although the more intense iri’adiation was delivered 
by radium. The primary uterine diseases comprised a number of condi- 
tions, both benign and malignant. The radiation therapy varied within 
wide limits, but in each case it was administered by an experienced gyne- 
cologist. Irradiation of the uterus preceded the onset of bladder symp- 
toms in the average ease by two and one-half years. The onset was sudden 
and often suffering was intense. Bladder symptoms consisted of fre- 
quency, dysuria, and hematuria. In some cases thei'e was extensive tis- 
sue destruction and even death. Cystoscopic examination showed ulcera- 
tion, anemic areas surrounded by intense inflammation, or punctate hemor- 
rhage. The lesion was situated in the posterior third of the bladder base 
in or near the mid-line. Diagnosis was based upon the history, vaginal 



DEAN : INJURY OP URINARY BLADDER 


675 


examination, V the cystoscopie picture, and a biopsy. Treatment' consisted 
of Tr. Hyoscyamus and codeine for pain, dilute phosphoric acid both by 
mouth and for bladder lavage, and instillations of argyrol and mercuro- 
chrome No. 220 (soluble). 


CONCLUSIONS 

1. Irradiation of the uterus occasionally is followed by injury of the 
bladder in spite of the most careful technic. 

2. Symptoms of bladder injury are frequency, dysuria, and hematuria. 
They usually begin many months after the uterine irradiation has 
been given. 

3. A woman of the cancer age who suifers with frequency, dysuria, 
and hematuria and who presents to cystoscopie examination an ulcerated 
condition of the bladder, may have either bladder cancer or a tertiary 
radiation reaction. 

4. One must not be misled into making an incorrect diagnosis, because 
if a radiation injury of the bladder is treated by radiation methods, as for 
cancer, the results are disastrous. 

5. Pain and infection often require resourceful treatment for many 
months. 

6. With careful management the end results are excellent in the ma- 
jority of eases. 

REFERENCES 

Dean, Archie L.,Jr.; J. A. M. A. 89; 1121, 1927. Mealy, William P. ; Ann. Surg. 
93; 451,1931. 

30 East Fortieth Street. 

ABSTRACT OF DISCUSSION 

DE. GEORGE G. WARD.— We have not paid enough attention to the complications 
of radium therapy. All who have used radium in carcinoma of the cervix particularly, 
and in the uterus and associated organs, have encountered similar experiences. 

A point brought out which is well worth emphasizing, is that we should not be in a 
hurry to make a diagnosis of extension of cancer to the bladder when evidences of ulcer- 
ation and slough are present following radiation. I can recall several cases in which 
the urologist stated that there was extension of cancer, but still the patients are alive 
and perfectly well today. I have one patient in mind that is well about nine years now. 
There was most extensive ulceration of the bladder with phosphatie deposits which 
cleared up entirely and the patient is perfectly well today. 

I would like to call attention to another point of interest in regard to injuries of the 
bladder following radiation; In some 558 eases of carcinoma of the cervix that I studied 
recently there were 40 in which supravaginal hysterectomy had been done for fibroids 
or some other condition prior to the development of cancer in the stump of the cervix. 
It was of interest to find that these cases are much more susceptible to damage of the 
bladder when radium is placed in the vaginal vault and cervix than in the ordinary case. 
After supravaginal hysterectomy, the bladder practically rests on top of the stump of 
the cervix, and when the tube of radium is placed in the cervical canal, the radium is 
very close to the bladder. We found that injury to the bladder occurred two and a half 
times more frequently in this series of eases than it did in the others. 

For a long period of time we have used an indwelling catheter to keep the bladder 
collapsed during the application of radium. We pack the vagina firmly to push the 



67G 


AMERrCAK JOURNAL OF OBSTETRICS AND GYNECOLOGY 


bladder and rectum as far away as possible. out of reach of the rays, and then the in- 
dwelling catheter keeps the bladder collapsed. We feel sure that we hare less bladder 
irritability when this is done. 

DE. H. E. CHAELTON. — I would like to say a word concerning the vital importance 
of the substance of this paper to men who are not particularly trained in or who have 
had little experience with the use of radium, and who are vulnerable to tlie persuasive 
advertising being carried on by various companies selling emanation. This has been 
brought closelj' to mj’ mind in the Westchester Cancer Committee w'here scarcely a 
month goes by that my attention is not drawn to a request received at the cancer office 
to furnish radium. Upon investigation we find not infrequently that the man who has 
requisitioned radium has been led without previous experience to apply it through the 
advertising of companies who stress the simplicity of carr3’ing out treatment but who 
give no warning of its devastating power. 

It seems to me that the Alcmorial Hospital and other teaching clinics in which radia- 
tion is being carried on, have a tremendous opportunitj' and a ver3' great responsibility 
in balancing this propaganda b3' bringing to the attention of men in practice the serious- 
ness of ultimate results of treatments which thc3’ have been persuaded were altogether 
simple. 

HE. WILLIAM P. HEALT. — Wc immediatcl3' refer each and every patient in the 
clinic who has dysuria or urinar3- frcquenc3‘ or an3- apparent new bladder symptom at 
once to the urologic clinic, and in this way we have been able to discover what seems Hke 
a reasonabl3' large number of instances of bladder disturbance resulting probably from 
radiation, and 3’ct in the sum tot.al it is not a very large number when you consider the 
vast number of patients that we hare treated there b}' radiation. If we treat cancer of 
the cervix with radiation therap3’, we must be prepared to meet with bladder complica- 
tions because wc cannot hope to get sufficient effect of radiation into the c.ancer and 
into the immediately surrounding parametria without bringing about changes in nutri- 
tion at the bladder base. 

Dr. Ward emphasized, and I agree with him, the value of the indwelling catheter 
in all cases in which radiation is used; whether it is a benign bleeding of the uterus 
where the dosage will be small, not over 700 or 800 or 1,000 me. hours, or whether it is 
for carcinoma, it seems to me that the catheter is ■\visel3' used and yet, on the other 
hand, it is interesting to note that in Dr. Dean's study of these cases the lesion is always 
in the part of the bladder that is fixed and does not change its position at all. 

The whole problem is so important that one must not use radiation because there is a 
bladder lesion, basing the radiation on the theory that there is cancer bi the bladder, for 
metastatic or reemrent involvement of the bladder mucosa with carcinoma in a cured 
ease of carcinoma of the cervix is extremel3' rare. 

We would like to know why in a fibrom3'omatous uterus of fair size where we have 
used only a small dose of radiation, filtered in the usual way (one-half a millimeter of 
gold and two of rubber ^vith two tubes and giving a dose as small as 1,200 me. hours) 
the patient develops a year or two later a lesion in the bladder. 

DE. HENEY D. EUENISS. — The radium effect on the bladder makes it more prone 
to infection, and in turn infection aggravates the condition and makes ulceration more 
bkely. 

I disagree with him on the subject of urinary antiseptics. I think that pyridium is 
of value, but that urotropin is ver3' apt to aggravate ulcerative lesions produced by 
radium. 

As Drs. Ward, Dean, and Healy have said, it is difficult sometimes from cystoscopic 
inspection alone to tell whether one is dealing with a recurrent carcinoma of the blad 
der or a radium lesion. I think one of the moat valuable differential diagnostic points 
is the lack of induration which can be felt per vaginam when the lesion is m the blad- 
der base ; also if one has a recurrence or extension to the bladder, he will see some 
evidences of it in the region of the primar3' lesion. 



A CLINICAL STUDY OF AVERTIN IN GYNECOLOGY 
AND OBSTETRICS* 

George Gordon Bemis, M.D., New York, N. Y. 

(From the Clinic of the Woman’s Hospital) 

W ITHIN recent years a number of new analgesic preparations have 
been introduced to the medical profession. Some of these after care- 
ful experimental and clinical studies have been found to be of great value ; 
others after an initial wave of enthusiasm have fallen into disrepute, either 
because they failed to produce the desired effect or the margin of safety 
was too restricted to warrant their use. 

Avertin is one of the new drugs widely advocated. It is chemically 
tribromethyl alcohol and was first synthesized in Germany in 1923 by 
Willstatter and Duisberg.^ Eichholtz- subsequently investigated its anes- 
thetic action in animals and man. In 1926 avertin was widely introduced 
into clinical practice in Germany by Butzengeiger.® At first large doses 
were given in an attempt to produce complete anesthesia with the result 
that a number of deaths directly attributed to it were reported. It was 
finally appreciated that doses sufficient to produce complete anesthesia 
were too dangerous and that the drug must in general be used only as an 
adjunct to an anesthetic. Recently Reuben Peterson and James Pierce* 
have reported favorably on the use of avertin in gynecology. As a result 
of observations in 300 consecutive cases they conclude that avertin more 
nearly approaches the ideal anesthetic than any other drug which has been 
employed. 

During the past two years avertin has been used frequently at the 
Woman’s Hospital. It is the purpose of this paper to report the clinical 
observations made in a series of 400 gynecologic patients, who were given 
avertin primarily as a Imsal anesthesia ; and 75 obstetric patients, who had 
avertin during the latter stages of labor for the relief of pain. 

character of cases included in gynecologic group 

Practically all races were represented. The ages ranged from fifteen 
years to eighty-four years. Eighty-five and seven tenths per cent of the 
patients were normal, except for the gynecologic conditions bringing 
them to the hospital The remaining 14.3 per cent had complicating medi- 
cal conditions, as shown in Table I. 

TYPES OF OPERATIONS 

All the usual gynecologic operations were performed in this group of pa- 
tients. Two hundred and forty-four (61 per cent) had laparotomies ; 117 
(29.2 per eent) had vaginal operations; 26 (6.5 per eent) had combined 

ber*13t\‘932^ invitation, at a meetingr of the New York Obstetrical Society, Decem- 

677 



678 


AJIERIOAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 
Table I. Complicating Medical Condition 


ADcmia (sccoDdary) 

Syphilis 

Uncomplicated hypertension 

Hypertension and myocarditis 

Hypertension and chronic valvular disease 

Uncomplicated chronic valvular disease 

Chronic myocarditis with auricular fibrillation 

Pyelitis 

Diabetes 

Hypothyroidism 

Chronic bronchitis 

Arrested tuberculosis 


NUMBER OP CASES 
25 
10 
9 
1 
1 
1 
1 
3 
2 
1 
2 
1 


Total 


57 


vaginal and abdominal operations; and 13 (3.3 per cent) were placed in a 
miscellaneous group, wbicli included 10 radical mastectomies and 3 opera- 
tions for hernia. 


ADMINISTRATION OF AVERTIN 

About one-third of the surgical patients were given a sedative on the 
night before operation. One hour before the scheduled time of the opera- 
tion a narcotic was administered. One hundred patients received a hj'po- 

Table II. Types op Operations 


NUMBER OP OPERATIONS 


Laparotomies : 

Hysterectomy 
Salpingooophorectomy 
Operation for retroversion 
Myomectomy 
Appendectomy' 

Separation of adhesions 
Exploratory laparotomy 
Sterilization, ligation of tubes 
Operation for acute intestinal obstruction 
Vaginal Operations : 

Plastic operations 
Vaginal myomectomy 
Vaginal hysterectomy 
Watkin ’s interposition 
Excision of vulva 
Dilatation and curettage 
Eemoval of Bartholin ej'st 
Repair of vesicovaginal fistula 
Posterior colpotomy 
Cystotomy 
Hemorrhoidectomy 

Combined Laparotomy and Vaginal Operations : 
Vaginal plastic and operation for retroversion 
Vaginal plastic and hysterectomy 
Vaginal plastic and appendectomy 
Vaginal plastic and salpingooophorectomy 
Vaginal plastic and ligation of tubes 
Vaginal plastic and repair of ventral hernia 
Miscellaneous Group : 

Radical mastectomies 
Hernia 


136 

S3 

26 

21 

15 

6 

4 

2 

1 

75 

4 

3 
1 
2 

24 

4 
I 
1 
1 
1 

13 

3 

3 

3 

3 

1 

10 

3 


Total 


400 




BEMIS: AVEBTIN 


679 


dermic of morphine gr. 1/8 and atrophine gr. 1/200 and 300 a hypodermic 
Imown as H. M. C. No. 2. This preparation consists of morphine gr. 1/8, 
hyosine gr. 1/200, and cactoid gr. 1/120. 

The avertin was given to the patient in her room one-half honr after the 
narcotic. It was administered as a retention enema in a 3 per cent solution 
of water at 40° C. To insure a satisfactorj’’ result the following precau- 
tions must be observed. A cleansing enema should be given six to twelve 
hours before the rectal instillation. The temperature must be exact. If 
heated much above 40° C., decomposition takes place, forming hydrobromic 
acid and dibromaeetaldehyde which is extremely irritating to the intestine. 
It should he injected slowly as rapid administration may cause marked 
cyanosis and circulatory depression. 

The dosage of avertin used in this series varied from 50 mg. to 100 mg. 
per kilogram of body weight and was dependent upon the condition of the 
patient. Anemia, cachexia, obesity, shock, hypertension, and a systolic 
blood pressure below 100 mm. of mercury were considered indications for 
smaller dosages of avertin. 


GENERAL. REACTION 

FollowiiLg the rectal injection, the patients gradually became drowsy 
and in many cases unconscious without any period of excitation or evidence 
of discomfort. It has been shown that avertin is absorbed rapidly from the 
rectum to the extent of about 80 per cent in the first twenty minutes. The 
time of onset of narcosis in this series varied from five to fifteen minutes 
and was dependent upon the dosage and the rapidity of administration. 
In the narcotized condition the patients were transported to the operating 
room. In eveiy ease there was complete amnesia, the patient recalling no 
event following the avertin until sometime after the operation. 

EFFECTS ON THE CIRCULATORY SYSTEM 

The action of avertin on the circulatory system has been carefully 
studied experimentally in animals by Raginsky, Bourne, and Bruger.® 
They have shown that concentrations of avertin in the circulatory system 
much higher than are found in the usual avertin anesthesia produce no 
deleterious effects upon the heart. They feel that avertin has a certain ac- 
tion on the peripheral circulation, but that this action is difficult to evalu- 
ate and appears to be of comparatively little importance. 

In this group of patients a clinical study of the action of varying doses 
of avertin on the circulation was undertaken by an analysis of the changes 
in pulse rate, systolic blood pressure and diastolic blood pressure. The pa- 
tients receiving morphine and atropine as a preliminary narcotic were 
studied independently from those given H. M. C. No. 2. 

We have observed the kind of preliminary narcotic did not influence ap- 
preciably the action of avertin ; and further that dosages of avertin vary- 
ing from 50 to 100 mg. per kilogram of body weight had no constant effect 
upon the circulation. 



G80 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGT’ 


Seventy-eight per cent of the eases showed an average increase in tlie 
pnlse rate of 15 beats per minute, while the remainder had an average de- 
crease of 8 beats per minute. The maximum increase was 52 beats per min- 
ute and the maximum decrease was 24. 

Eighty-seven per cent had an average drop in systolic blood pressure of 
22 mm. of mereurj'- and the other eases had an average increase of systolic 
blood pressure of 12 mm. of mercury. The maximum drop was 84 points 
and the maximum increase was 27 points. 

Two-thirds of the patients showed an average drop in the diastolic blood 
pressure of 16 mm. of mercury with a maximum of 42 mm. of mercury, 
while one-third had an average increase in the diastolic pressure of 10 mm. 
of mercuiy with a maximum of 36 mm. of mercury. 

EFFECT ON THE RESPIRATORY SYSTEM 

The action of avertin on the respiratoiy system was not constant. The 
amplitude of respirations was usually reduced but the respiratory rate 
might be slightly increased or decreased. 

EFFECT ON THE KIDNEYS 

The effect of avertin administration upon the kidneys has been carefully 
studied experimentally. Avertin is detoxified in the liver by combining 
as a coupled compound with glycuronie acid and is eliminated in this man- 
ner almost entirely by the kidneys. Veal, Phillips and Brooks® have found 
that while the coupled compound of avertin and glycuronie acid is 
promptly excreted by a normal kidney, it is not excreted by an injured 
kidney and that death results from the accumulation of avertin and the 
prolongation of its action. 

In this series 17 per cent had a transient albuminuria on the day follow- 
ing operation and 2 per cent had albumin and casts. One patient had a 
temporary urinary suppression for twenty-four hours. 

SUPPLEMENTARY ANESTHESIA 

Nitrous oxide and oxygen, nitrous oxide oxygen and ether, or ether 
alone were the anesthetics used. In only 4.5 per cent of the patients was it 
possible to perform the operation without an anesthetic. Twenty-one per 
cent had nitrous oxide and oxygen ; 71.5 per cent nitrous oxide oxygen and 
ether ; and 3 per cent had straight ether. The amount of ether required 
was dependent more upon the duration of the operation than upon the 
initial dosage of avertin and varied from an average of 1.5 ounces in 
vaginal operations to 4.1 ounces in combined vaginal laparotomy cases. 

COMPLICATIONS OCCURRING DURING THE ANESTHESIA ATTRIBUTED TO A^^!)RTIN 

An analysis reveals that 7.5 per cent had an unfavorable reaction dur- 
ing the anesthesia which could entirely or in part be attributed to the 
avertin. The reaction was either a depression of the circulatory or respira- 
tory system or of both systems. 



BEMIS: A\TiRTIN 


G81 


Age and dosage did not appear to be a definite factor in the reactions. 
The ages ranged from twenty-nine to sixty-nine years and the dosages in 
which reactions occurred varied from 60 mg. to 100 mg. per kilogram of 
body weight. Patients acutely toxic or in shock and frequently hyperten- 
sion eases did not react well to avertin. The other medical complications 
encountered in this series had no apparent influence on the patient’s 
reaction. 

Patients in whom there was a marked circulatdry depression were 
greatly improved by a subcutaneous injection of 1 c.c. of ephedrine. The 
respiratory depressions were treated by giving caffein sodium benzoate 
gr. 7.5 and carbon dioxide. 

Table III. Postoperative Complications 


NUMBER OF CASES 

Pyelitis 18 

Pneumouia 4 

Thrombophlebitis 4 

Acute peritonitis 2 

Suppression of urine (temporary) 1 

Pleurisy 1 

Postoperative psychosis 1 

Embolism of pulmonary artery 1 

Hemiplegia 1 

Total 33 


POSTOPERATIVE COURSE AND COMPEICATIONS 

The immediate postoperative course of the first six to twelve hours was 
characterized by fewer complaints than usual. The patients slept or were 
in a semiconscious state for a period of two to six hours. Their awakening 


Table IV. Mortality 


diagnosis 

MG. OF 
AVERTIN 

OPERATION 

TIME OF 

DEATH 

CAUSE OF 

DEATH 

1. Acute peritonitis 

100 

Laparotomy 

1 hr. 

Acute peritonitis 

2. Acute peritonitis 

80 

Posterior colpotomy 

6 hr. 

Acute peritonitis 

3. Acute intestinal ob- 
struction 

60 

Laparotomy 

18 hr. 

1 Intestinal obstruc- 
tion 

4. Carcinoma of ovaries 

80 

Hysterectomy 

Salpingo- 

oophorectoniy 

24 hr. 

Thrombosis of infe- 
rior vena cava 

5. Myoma uteri 

80 

Hysterectomy 

3rd day 

Acute peritonitis 

6. Myoma uteri 

70 i 

Hysterectomy 

10 hr. 

Postoperative shock 
and hemorrhage 

7. Carcinoma of breast 

60 

Radical mastectomy 

7th day 

Bronchopneumonia 

8. Myoma uteri 

80 

Hysterectomy' 

12th day 

Pulmonary embolism 

9. Blyoma uteri 



3rd day 

Peritonitis 












































682 


A^MERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


approached more nearly that of a natural sleep. Fifty-two per cent had 
no vomiting or even nausea. In no instance did a patient complain of 
rectal irritation. 

The following complications occurred ; as shown in Table III. 

MORTALITY 

There were 9 deaths in the series of 400 eases. In no instance could the 
death be directly attributed to avertin. 

In the first three cases it is quite probable that avertin hastened an in- 
emtable death and in this sense might be considered a contributing cause. 
All three patients were acutely ill and A-ery much depressed by an over- 
whelming toxemia and tliis depression Avas accentuated by the administra- 
tion of aA^ertin. It is apparent that avertin is not safe for patients in shock 
or depressed by sepsis or other toxic conditions. 

AA'ERTIN IN OBSTETRICS 

The ideal obstetric analgesia should fulfill the follovung requirements; 
it should be possible to administer AAithout delaying the progress of labor ; 
the patient should be relieved for a reasonable period of time ; the drug 
must be fairly consistent in action and should have no undesirable effects 
upon either the mother or the baby; and the administration should not be 
too complicated. 

There is a difference of opinion regarding the value of avertin in ob- 
stetrics. Ed. Martin^ in a series of 4,500 cases I'eports that the procedure 
has none but the most salutarj^ effects on mother and child. Schroeder® 
using the same method as Martin in a series of 110 cases reports that in 28 
per cent the relief of pain Avas good, in 52.8 per cent it was fair, and in 10.9 
per cent the method failed. He also states in 15 per cent deliveiy was de- 
layed and in 22 cases atonic hemorrhage occurred. WeibeP feels that 
aA'^ertin is of Amine only during the expulsive period and that in the initial 
stages of labor other preparations should be used. Dodeld® in a graphic 
study of the uterine contractions during labor following the administra- 
tion of Amrious analgesias came to the conclusion that aAmrtin given by 
rectum in doses of 60 mg. per kilogram had no marked influence upon 
uterine contractions other than to prolong greatly the inteiwal between 
them. He further states that after about forty-fiA'e minutes the uterine 
contractions resume their former frequenc5'’ and painfulness. 

CHARACTER OF CASES IN OBSTETRIC GROUP 

The group of obstetric patients studied was composed of 75 noimal 
women. Their ages ranged from seventeen to forty years. Forty-three 
were primiparas and 32 Avere multiparas. All had vertex presentations 
except two ; one an undiagnosed brow, and the other an undiagnosed face 
presentation. Twelve of the vertex presentations were in an occipitopos- 
terior position. 



BEllIS: AVERTIN 


683 


CONDUCT OF LABOR 

The use of avertin for relief of pain was limited in this series of cases to 
the latter part of the first stage of labor and to the second stage of labor. 
It was administered to the primiparous women when the cervix was ef- 
faced or almost fully so and the uterine contractions were at intervals of 
three to five minutes. The multiparous women, if progressing rapidly 
were given avertin when the cervix was dilated 6 to 7 cm. and if progress- 
ing slowly the avertin was withheld until fully dilated. 

Until this degree of dilatation was obtained, the patients in the early 
stage of labor were partially relieved by a hypodermic which consisted of 
morphine gr. 1/6 to gr. 1/8 combined with scopolamine gr. 1/150 to 
gr. 1/200. The hypodermic was given 43 patients (57.3 per cent) after 
labor was definitely established ; i. e., the contractions were moderately 
strong at intervals of three to five minutes, the cervix was dilated at least 
3 cm. and the patient anxious for relief. In 3 cases it was necessary to re- 
peat the hypodermic as labor had not progressed to the point where avertin 
could be administered. The remaining 32 patients (42.7 per cent) who 
did not receive a hypodermic, were either not particularly distressed or 
they were ready for avertin when they arrived in the hospital. 

The dosage of avertin was 60 mg. to 70 mg. per kilogram of body weight 
and the method of administration was the same as in the surgical group. 

RESULTS 

The patients following the administration of avertin became drowsy 
and very often fell asleep between pains. During this period which usually 
lasted thirty to forty minutes, the uterine contractions were generally 
weakened and the interval between them lengthened. After the initial 
stage of narcosis, labor gradually became more active and usually 
within an hour and a half to two hours the contractions were as frequent 
and painful as they were before the avertin. 

Tables V and VI summarize the group as to the degree of relief of pain 
and the effect on progress of labor during this period ; and also it contrasts 
the results obtained in patients who had a preliminary hypodermic of 
morphine and scopolamine with those who had only avertin. 

In the morphine, scopolamine and avertin group of 43 patients, 6 pa- 
tients (14 per cent) were completely relieved of pain; and of the 6 cases, 
labor was not influenced in 3 (7 per cent) , was retarded in 2 (4.7 per cent) , 
and was stopped in one (2.3 per cent). Thirty-three patients (76.7 per 
cent) of this same group were partially relieved of pain ; in 9 of these cases 
(20.9 per cent) labor was not influenced, in 13 (30.2 per cent) labor was 
retarded, and in 11 (25.6 per cent) labor was stopped. There was no re- 
lief of pain and no interference with the progress of labor in 4 cases (9.3 
per cent). 

In the group of 32 patients who only had avertin, 5 (15.6 per cent) were 
completely relieved of pain, and of the 5 patients, labor was not influenced 



684 


AJIERICAN JOURNAL. OF OBSTETRICS AND GYNECOLOGY 


Table V. Belief of Pain and Influence of Drugs on Labor 



MORPHINE SCOPOLAMINE AND AVERTIN 


PRlMIP. 

MULTlP. 

NO. 

TOTAL 

PER CENT 

Complete Relief of Pain: 





Labor not influenced 

1 

2 

1 3 

7 

Labor retarded 

1 

1 

O 

4.7 

Labor stopped 

0 

1 

1 

2.3 

Partial Relief of Pain: 


1 


20.9 

Labor not influenced 

7 

2 

9 

Labor retarded 

10 

3 

13 

30.2 

Labor stopped 

10 

1 

11 

25.6 

Ko Relief of Pain: 




9.3 

Labor not influenced 

0 

4 

4 

Labor retarded 

0 

0 

0 


Labor stopped 

0 

0 

0 


Nnmhcr of Cases 

29 

14 

43 

100.0 


Table VI. Belief of Pain and Influence of Drugs on Labor 


Complete Belief of Pain. 
Labor not influenced 
Labor retarded 
Labor stopped 

Partial Relief of Pain: 
Labor not influenced 
Labor retarded 
Labor stopped 

iVo Relief of Fain : 
Labor not influenced 
Labor retarded 
Labor stopped 

Nnmhcr of Cases 


avertin 


FRIMIP. 


/ 

4 

0 


0 

0 

0 

14 


JIULTIP. 


3 

0 

0 

18 


TOTAL 

jIO. PER CENT 


13 

8 

3 


3 

0 

0 

32 


9.4 

6.2 


40.G 

25.0 

9.4 


9.4 


100.0 


i. ;i /I In 9 Ifi 2 Der C6Dt) and. was not stopped 
in 3 (9.4 per cent), was retarded in 2 6-2 ^ 

in any case. In this same in 13 

partially relieved of ptun and in tl 3 

(40.6 per cent), r t Td 4 per cent) who had no relief of pain fol- 

cent) . There were 3 patients (9.4 pei cent; wi 

lowing avertin hut co^itinned to morphine, scopolamine 

From a comparative study of the 5 ,ioup „,rpi,tin CTable VI) , it 

andavertta (TaWeV) «« p-oap -ho had onb, t.u (^‘c J, 
appears that morphine and scopolamnie m comhmahon 






BEMIS: AVERTIN 


685 


while insuring more certaiir relief from discomfort, results in a sliglitly 
greater tendency to delay the noi-mal progress of labor. 

There was complete amnesia after the avertin in 29 per cent of the cases, 
partial amnesia in 62 per cent, and no amnesia in 9 per cent. 

Nineteen patients had normal deliveries. Forty-one Avere delivered by 
low forceps. The indication Avas given in 34 of these cases as prophylactic, 
in 4 cases as extreme restlessness and lack of cooperation folloAving the 
aA'ertin ; and in 3 eases uterine inertia as a result of avertin administration. 
Seven patients were delivered by mid-forceps ; in 4 the indication Avas a 
slight disproportion, in 2 restlessness after avertin, and in one uterine 
inertia following aAmrtin. Eight patients Avere delivered by a Scanzoni 
rotation and medium forceps because of a persistent oecipitoposterior 
position. 

Sixty-tAVO babies Avere born without any signs of asphyxia, 11 babies 
were slightlj'’ asphyxiated at birth ; but did not require resuscitation. The 
cause of this slight asphyxia Avas undetermined in 4, all Ioav forcep de- 
liveries ; possibly aA'ertin in 3, one a normal delivery and the other two 
low forcep deliveries; a difficult delwei’y was considered the cause in 3 
other eases; inhalation of mucus in one; tight cord around the neck in 
one ; and difficulty in extracting the shoulders in another case. The 2 cases 
Avhere the asphyxia was more marked and required resuscitation were both 
instrumental cases ; one a Scanzoni rotation and mid-forceps delivery, and 
the other case was a low forceps delivery. 

Sevent 3 '’-tAvo mothers were in good condition and 3 mothers Avere con- 
sidered in poor condition immediatelj’- folIoAving delivery. Two of the 
latter patients developed symptoms of shock, in one case it was attributed 
to fatigue following a prolonged labor of thirty-nine hours and a mid- 
forceps deliverj^ ; in the second case one of pronounced hjffiraranios, it fol- 
loAved immediatelj^ after rupture of the membranes and deliverJ^ In the 
third case avertin Avas considered probably a contributing factor. This 
patient had an uneventful first and second stage of labor. Following de- 
livery the uterus remained relaxed and the patient lost about 750 c.c. of 
blood. All 3 cases reacted promptly following a gum glucose infusion. 

There was no maternal death nor Avas there any stillbirth. 

UNDESffiABLE REACTIONS ATTRIBUTED TO AATiRTIN IN THE OBSTETRIC GROUP 

Lack of cooperation and difficulty in managing the patients during the 
uterine contractions frequently folloAved the administration of avertin. 
There Avas a tendency to grasp the external genitalia Avhen in pain. Ex- 
treme restlessness was a troublesome factor in 9.3 per cent of the cases. 

Atony of the uterus occurred in 9 cases (12 per cent). Eight patients 
had bleeding varying from slightly more than normal to a hemorrhage of 
500 c.c. One patient had a hemorrhage of 750 c.c. This tendency to relax- 
ation Avhen it occurred lasted for a period of one to three hours and re- 
quired constant Avatching during this time. 



686 


a:\ierican journal of obstetrics and gynecology 


CONCLUSIONS 

1. Aveitin can be safely and advantageously used as a basal anesthetic 
in selected surgical cases. 

2. The effect on the circulatory and respiratory systems is inconstant. 

3. Tlie unfavorable reactions noted in this series were depressions 
of the circulatory and respiratory systems. The apparent predisposing 
factors for these depressing effects were shock, profound toxemia, and 
hypertension. 

4. Complete anuiesia, absence of the immediate preoperative emotional 
agitation, lessening of the amount of ether required for anesthesia, and a 
more comfortable iiostoperative convalescence are reasons for advocating 
the use of avertin in gjuiecologjL 

5. There were no deaths directly attributed to avertin, but in 3 patients 
who were acutely toxic ; two from sepsis and one from an acute intestinal 
obstruction it probably hastened death by its depressing effects on these 
patients. 

6. The usefulness of avertin in obstetrics during labor is limited greatly 
by its frequent failure to satisfactorily relieve the patient of pain and at 
the same time allow labor to progress. Its use is further restricted by the 
relatively short duration of satisfactory action. 

7. Obstetric iiatients under the influence of avertin frequently become 
extremely restless, uncooperative, and difficult to manage. 

8. Postpartum atony of the uterus with abnormal blood loss is not an 
unusual complication. 

9. Avertin apparently has no unfavorable effects upon the baby. 


REFERENCES 

(1) TVillstatter, E., mid Duisherg, W.: Beitr. d. deutsch. Cliem. Gesellscli. 54: 
2283,1923. (2) Btc/UiolJg, I?’,: Deutsche med. Wclinschr. 53: 710, 1927. (3) Eutsen- 

geiger, 0.: Deutsche med. Wchnschr. 53: 712, 1927. (4) Eeterson, E., and Pwree, J.: 
Surg. Gyuec. Obst. 55: 191, 1932. (5) EaginsToy, E., Bourne, W., and Burger, M.: 

J. Pharmacol. & Exper. Tlierap. 43: 219, 1931. (6) Veal, J., Pliillips, J., and Broohs, 
C. : J. Pharmacol. & Exper. Therap. 43: 637, 1931. (7) Mariin, B.: Med. ^8: 
1036, 1930. (8) Schroeder, C.; Monatschr. f. Geburtsh. u. Gynah. 84: 235, 1930. (9) 
Weibel, IF..- Artzl. Prax. 2: 46, 1929. (10) Dodeb, S..' Surg. Gynec. Obst. 55: 45, 

1932. 


121 East 60 Street. 

ABSTRACT OF DISCUSSION 

DR. GEORGE G. COCHRAN.— I reported recently a series of 150 similar cases 
from the Brooklyn Hospital, and it might be of interest to compare results. ^ 

The routine generally followed was morphine and scopolamine hypodermically until 
the cervix had become effaced and dilatation had progressed to about one inch. ^ At t ns 
time a 60 mg. per kilogram dose of avertin w-as given by rectum and uhen iiidica e , a 

second or third dose at three-hour intervals. 

In our series five-sbctlis of the patients were primiparas and no prolongation of labor 
was noted. The method of delivery was cesarean section 3 ; high forceps 1 ; low creeps 
12; forceps control and perineotomy 101; spontaneous vertex 26; spontaneous breeei 
3 ; breech extraction 4. With this high incidence of forceps control, it is rathei bar 
judge the duration of the second stage. We are of the impression la in a num 
cases there was a definite retardation of the progress of labor in the second s age. 



BEHNEY: PELVIC SYMPATHECTOMY 


687 


There were 4 stillbirths, none attributed to avertin. Also 6 of the babies required 
resuscitation. There were no maternal deaths. 

Our results were tabulated after the method of the Boston Lying-in Hospital. Of 
the 32 patients receiving two doses of avertin 5 remembered clearly ; 15 remembered 
vaguely; and 17 remembered nothing concerning their labor. Two patients receiving 
three doses remembered vaguely. One hundred and one patients received one dose. 
Twenty of these remembered clearly; 65 remembered nothing; and 30 vaguely remem- 
bered their experiences. Of the 25 who remembered clearly 20 said they had a hard 
time ; the other 5 said they had an easy time, and that they had received considerable 
relief from the medication. 

I feel that avertin produces a successful state of analgesia or amnesia, but in many 
cases more nursing care was needed than with some of the other agents such as the 
Gwathmey ether-in-oil routine. 

In cesarean section operations we feel that avertin used purely as a basal anesthetic 
has the advantage of relieving the preoperative anxiety and lessening the postoperative 
discomforts. 

BE. W. P. CONAWAY. — In the Atlantic City Hospital avertin anesthesia has been 
used in very few obstetric cases, less than six, I think, because it was not considered 
especially valuable, but in gynecology and general surgery up to Dec. 1, 1932, it has 
been used in about 536 eases. When we first began to use it, we did not consider it 
especially valuable on account of the prolonged narcosis. One patient slept for about 
twenty-two hours and required the constant presence of a nurse. Since using it as a 
basal anesthesia only, supplemented by gas-oxygen, but never ether, we have used it 
more routinely. On my service up to Dee. 1, 1932, we have used it in 125 major opera- 
tions supplemented by gas-oxygen. 

DE. F. C. HOLDEN. — I have used avertin in private work in the last three years 
rather extensively. It is very essential that the patient who has had avertin, have the 
exclusive services of a nurse until entirely out of the anesthetic, since the patient may 
‘ ‘ swallow her tongue ’ ’ and if not closely Avatched, this might have a fatal outcome. It 
is a Avise procedure not to remove the throat tube until the patient coughs it out. 


PELVIC SYMPATHECTOaiY FOR PAIN IN CARCINOMA 
OP THE CERVIX^- 

Charles Augustus Behney, M.D., Philadelphia, Pa. 

fFrom the Department of Obstetrics and Gynecology, University of Pennsylvania) 

TNTERRUPTION of portions of the abdominal sjunpathetic system for 
the relief of pelvic pain, proposed and carried out by Jaubanlay in 1899, 
received little immediate recognition from the medical world. More than 
tAventy years later a variety of operations upon the abdominal and pelvic 
autonomic nervous mechanism were developed in Europe, for the most part 
by French surgeons. So satisfactory were the results reported by these 
woikers, that pi'ocedures of abdominal and pelvic sympathectomy were 
gradually adopted by operators on the continent and Australia. In the 
United States interest in abdominal sympathetic surgery has been less en- 
thusiastic and the small amount of Avork done along these lines has been 
perform ed mainly by neurosurgeons Avho have applied it to a variety of 

•Read at a meeting of the Obstetrical Society of Philadelphia, November 3, 1932. 



688 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGT 


indications, mostly extrapelvic in nature, sucli as Baynand’s disease, Hir- 
schspining’s disease, caudalgia, and intermittent claudication, in the lower 
extremities. A comparatively small number of patients with dysmenor- 
rhea have been treated in this way by Grant, Adson, and others. 

Fontaine and Hermann in their recent monograph on this subject, and 
others (Ootte, Leriehe, and Bittmann), most enthusiastically recommend 
surgery of the pelvic sj’^mpathetic nerves, not only for so-called essential 
dysmenorrhea, but for other gynecologic conditions such as ovarian neu- 
ralgia, and the pain of advanced pelvic carcinoma. Curiously, this work 
has failed to impress American gA-necologists, and we have been unable to 



find reports of its application, in this country for the relief of pam m pa- 
tients with hopeless pelvic malignant neoplasms. _ 

Notwithstanding improvements in 

roentgen therapy, carcinoma whose 

obstruction, et cetera, there are ^ ^ administration of enor- 

suffering baffles all attempts at reli , therefore, to in- 

mous and increasing doses of , i.easonable promise of adding some 

vestigate any suggestion ^ J ^ind, after a study 

degi’ee of comfort to such women. AA'ith tnis purpu 



BEHNEY: PELVIC SYMPATHECTOMY 


689 


of the literature and examination of the regional anatomy on cadavers, ab- 
dominal sympathectomy vias attempted upon seven patients, all with ad- 
vanced carcinoma of the cervix. 


ANATOMY 

The afferent visceral-sensory fibers from the uterus, the adnexa, and the rectum, pass 
to the inferior hypogastric plexuses, which are situated lateral to the vagina and rectum 
on the posterior fold of the broad ligaments. The inferior hypogastric plexuses unite 
at the level of the sacrum and become the superior hypogastric plexus. Some fibers 
from the uterus reach the superior hypogastric plexus through the uterosacral liga- 
ments and some enter the ganglionated cord more directly by way of the sacral plexuses. 
The fibers of the superior hypogastric plexus pass upward, some to the aortic plexus 
which encircles the aorta, and others beneath the iliac arteries, to reach the lumbar 
ganglia of the sympathetic cord. All these fibers eventually reach the posterior roots of 
the spinal nerves, in whose ganglia are situated the neurones of which the afferent vis- 
ceral sensory fibers are the dendrites. The visceral sensory impulses continue to the 
posterior horn of the spinal cord by way of the posterior root of the spinal nerves. The 
fibers pass without interruption from the viscus to the spinal cord. 

The ganglionated cords, in the lumbar region, lie beneath the aorta on the left side 
and beneath the inferior vena cava on the right side and upon the lumbar vertebrae. 
They are mesial to the inner borders of the psoas muscles. The aortic plexus surrounds 
the aorta from the origin of the inferior mesenteric artery to the bifurcation into the 
common iliac arteries. 

The superior hypogastric plexus (also named the presacral nerve of Laterjet and 
Kochet) consists usually (in 80 per cent of eases) of a very complicated network of 
nerve fibers. It is sometimes condensed into two distinct cords and occasionally is seen 
as a single large nerve trunk. Lying ventral to the sacral promontory upon the pre- 
vertebral fascia and immediately beneath the posterior parietal peritoneum, it is some- 
times visible in emaciated subjects. Its fibers are continuous rvith those of the aortic 
plexus above, and at its lower end this plexus divides into the two inferior hypogastric 
(pelvic) plexuses. These fibers are closely associated with the adventitia of the in- 
ternal iliac vessels and their branches. 

The operations proposed for the relief of pain due to pelvic malignancy 
are : lumbar ganglionectomy, excision of the aortic plexus, excision of the 
superior hypogastric plexus (Hovelacque), and periarterial sympathec- 
tomy of the internal iliac arteries. Numerous surgeons, including Tis- 
serand, and Grant, consider a combination of the latter two procedures the 
operations of choice, while other authorities, among whom are Fontaine 
and Hermann, advise the combined procedures of resection of the superior 
hypogastric and aortic plexuses and lumbar ganglionectomy. Cotte and 
Leriche have found extensive hypogastric plexus excision adequate. 

OPERATION 

After the customary preparation for a laparotomy, with the patient in 
extreme Trendelenberg position, a mid-line incision is made from the 
sjonphysis to the umbilicus. The ileum is carefuUy packed into the upper 
abdomen and the sigmoid is drawn to the left, where it is held by a gauze 
sponge and a retractor. The superior hypogastric plexus is now ap- 
proached by incising the posterior parietal peritoneum at the level of the 
sacral promontory. The incision is continued upward to the bifurcation 



690 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


of the aorta and downward for a sufficient distance to expose the retro- 
peritoneal tissues for 5 or 6 cm. The peritoneum can be separated from 
the underlying structures by blunt dissection until it has been elevated 
laterally as far as the common iliac arteries. This step exposes the superior 
hypogastric plexus, enveloped in fibrous tissue and fat, and in thin sub- 
jects the glistening components of the plexus may be readily seen. When 
obscured by subperitoneal fat, the nerve fibers must be teased out and iso- 
lated. The fibers are then easily raised from their bed by blunt dissection. 
Separation to the left of the mid-line, where the plexus will be found in 
close relationship with the left common iliac vein, must be done carefully 
and gently to avoid in juiy of this important vessel. After all, nerve fibers 
have been elevated for a distance of 6 cm. below the bifurcation of the 
aorta, a Pagensteeher ligature is placed about the plexus at this point and 
the nerve tissue is divided. All of the fibers situated between the iliac 
arteries and upon the prevertebral fascia are removed to the level of the 
bifurcation of the aorta. 

Removal of the aortic plexus (periaortic sympathectomy) requires up- 
ward prolongation of the incision. It is performed by removing the plexus 
on the aorta, as far as the origin of the inferior mesenteric artery. Fibers 
overlying the inferior vena cava should also be teased away and divided. 
If at this point the inferior vena cava is gently retracted toward the mid- 
line, the ganglionated cord on the right will be seen lying mesial to the 
right psoas muscle. Similarly, by retracting the aorta mesially, the left 
ganglionated cord is exposed. A portion of each of these structures suf- 
ficient to include the third and fourth lumbar ganglia, should be resected. 

The internal iliac arteries are located at the bifurcation of the common 
iliacs, and after incising the parietal peritoneum at this point, the artery 
is seen in close relationship with the corresponding ureter. The latter im- 
portant structure is separated from the vessel by blunt dissection and re- 
tracted. The adventitia of the vessel with the sympathectic structui’es con- 
tained in its substance is then removed from the origin of the vessel for a 
distance of several centimeters. 

Unless one of the more important vessels has been injured accidentally, 
there is rarely troublesome bleeding. The few small vessels to the plexuses, 
which must be dmded in order to remove the nervous structures, are 
clamped and ligated with linen ligatures. When assured that satisfactory 
hemostosis has been secured, the peritoneal incisions are closed ivith con- 
tinuous sutures of fine chronic catgut, and the operation is then concluded 
with the usual technic for anj’- laparotomy. 

Several operative procedures were used in this series for the purpose of 
comparison and for expediencj''. This report concerns seven patients upon 
whom pelvic sjonpathectomies were attempted. Only patients in extieme 
pain from stage four carcinoma of the cervix were selected and they have 
been followed up to the present time or for the duration of their lives. 
Complete and permanent relief of pain in the lower abdomen and thig s 



BEHNEY: PELVIC SYMPATHECTOMY 


691 


from the time of operation was the criterion of success. Four of the seven 
patients were ambulator}^ and three were bed-fast before operation. Four 
of the group are dead. One died nine days after sjonpatheetomy from 
uremia ; the second, two and a half months after the operation, from the 
same cause. Two patients died at home, one from an imeontrollable diar- 
rhea, two months after treatment, and the other from hemorrhage, four 
and a half months postoperatively. Three are still alive, three weeks, three 
and one-half months, and four and one-half months after sympathec- 
tomy, respectively. Since only very advanced patients were selected for 
this work, the relativel3^ short duration of life in most instances is not 
surprising. 

Table I 


BATIENT 

OPERATION * 

1 1 

RESULT 

B. G. 

Resection superior hypogastric plexus 

Relieved 

A. DeG. 

Resection superior hypogastric plexus 

Failed 

B, A. 

Resection superior hypogastric plexus. Internal iliac peri- 



arterial sympathectomy 

Relieved 

K. S. 

Sympathectomy impossible (Left iliac vein injured) 

Failed 

S.TJ. 

Resection superior hypogastric plexus. Internal iliac peri- 



arterial sympathectomy 

Relieved 

M.L. 

Resection superior hypogastric plexus. Internal iliac peri- 


1 

arterial sympathectomy 

Relieved 

V.S. 

Resection aortic and superior hypogastric plexuses (Inf. mes- 



enteric artery injured) 

Relieved 


All incisions healed by first intention and there were no postoperative 
complications. In spite of the extensive involvement of the bowel with 
metastatic carcinoma, the slight amount of distention and gas pains was a 
striking feature in the convalescence of each case. Frequent defecation 
for from four to eight days was noted in four patients. In two patients 
diarrhea accompanied the formation of rectovaginal fistulas and in one of 
these was apparently the cause of death. Incontinence of feces for two 
dash’s, without a fistula, was noted in one instance. One woman was incon- 
tinent of urine on two occasions within the first forty-eight hours, a second 
once during the first forty-eight hours, and a third once during the first 
twenty-four hours after operation. Two patients required catheterization. 
Eeddish-blue blotching of the extremities was noted in two of the five white 
women. 

In two instances the operation failed. Excision of the superior hypo- 
gastric plexus was done for the first of these. The plexus in this instance 
was condensed into two large cords. The section evidently failed to in- 
clude all afferent fibers. 

The second failure was in a nullipara, aged twenty-three, who had wide- 
spread metastases with the omentum so densely adlierent to the fundus of 
the uterus and the iliac arteries that exposure of the sympathetic plexuses 
was impossible. In this instance, there was not the slightest relief from 








692 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


pain and tlie patient died in the hospital after ten weeks of almost con- 
tinual narcotization. This mortality can hardly be attributed to the 
operation. 

Of the operative procedures which have been proposed for the relief of 
pain from advanced pelvic eareinoma, sjunpathectomy has much to recom- 
mend it to pelvic surgeons. While a neurosurgical jirocedure, it is dis- 
tinctly within the field of the gynecologist. Its performance affords all of 
the advantages of an exploratory laparotomy, permits the securing of tis- 
sue for histologic diagnosis and allows one to study the metastatic habits 
of the various types of malignant groAvths. Unless troublesome adliesions 
are encountered, sympathectomy is neither difficult nor time consuming. 
The incision is so situated tliat it produces no discomfort during convales- 
cence, and its healing is not adversely influenced by the recumbent posture. 
There is no disturbance of cutaneous sensation or motor function in the 
lower extremity. 

In our small series, despite the poor physical condition of most of our pa- 
tients, the operation was borne surprisingly well. A mortality rate of 
even 14 per cent, should be reduced by earlier intervention and restriction 
of the field for such work to patients having a reasonable life expectancy. 
The indication for these procedures is pain which is not relieved by ordi- 
nary analgesics or x-ray therapy. Though our results are less than should 
be desired, we feel that operations of this type deserve further trial and 
hope that gi’eater experience will enable us to apply them ivith more uni- 
form success. Their fair evaluation requires observation of a larger series 
of eases. 


REFERENCES 

(1) Adson, Alfred TV., and Brown, George E.: Surg. Gynec. Obst. 48: 577-603, 1929. 
(2) Bittmann, 0.: Lyon. Chir. 22: 757-7SS, 1925. (3) Cotte, G.; Gynec. et Obst. 23: 
233-244, 1931. (4) Cotte, G., Ucdiaime, 31. ; J. de Chir. 25 : 653-664, 1925. (5) Fon- 
taine, Herman : Surg. Gynec. Obst. 54: 133-161, 1932. (6) Grant, Francis G.: Pemm. 

M. J. 34: 792-797, 193i. (7) dcGrisogono, A.: Ann. d. Obst. i ginec. 51: 567-589, 

1929. (8) Jianw, <7^. • Bev. f rang, de Gyndc. et d ’obst. 23: 518-524, 192S. (9) Lcriclie, 

L.: La Presse med. 33; 465,1925, (10) Lcriclie, E.: Lyon. Ciiir, 22; 701, 1925. (H) 
Piersol, George A.: Human Anatomy, ed. 4, Philadelphia, 1907, J. B. Lippincott Co. 
(12) BanTcin, Fred TV., and Learmouth, James F.: Ann. Surg. 92: 710-720, 1930. (13) 
Feld, Mont. F., and DeTVitt, William: Surgery of the Autonomic Nervous System, 
Practice of Surgery 3: Chap. Viri, Hagerstown, 3Id., 1929, W. P. Prior Co., Inc., pp. 
44-55. 

133 South Thirty-Sixth Street. 

ABSTRACT OP DISCUSSION 

DR. OSCAR V. BATSON.— Surgical intervention for the relief of visceral pain may 
be effective in two ways. Relief may come from the sectioning of affeient, pain fibers 
or it may come from sectioning the efferent fibers to the blood vessels. The one method 
is palliative and the other is, in a measure, restorative. The sectioning of the pain 
fibers, which although accompanying the sympathetic fibers may not be sympat letic 

nerves, has obviously a wider clinical application. 

When the pain is present due to a vascular disturbance, as in dysmenorr lea, a sec 
tion of the nerves supplying the blood vessels is no doubt responsible for t le re e . 
pelvic carcinoma we may be dealing with pain due to vascular disturbances or, w 



BEHNEY: PELVIC SYMPATHECTOMY 


693 


more likely, -svitli direct irritation of the pain fibers by the enlarged lymphatics. In 
this connection Franz Kiss pointed out the intimate intertwinings of the visceral sym- 
pathetic and lymphatic systems. 

The presence of pain fibers in the sympathetic system is found elsewhere in the body, 
for example even with excellent nerve block anesthesia the dentist produces consider- 
able pain in exposing the tooth pulp. This pain seems to be relieved by anesthetizing 
the sphenopalatine ganglion. 

It is rather hard to conceive of all of these fibers going to the ganglion, as illustrated 
in Dr. Behney ’s charts. That brings me to mention that we do not know definitely the 
course of these pain fibers, and until that course is definitely plotted we may expect 
some irregularity in results. 

I would like to ask Dr. Behnej’’ how many times this particular procedure has been 
employed in pelvic carcinoma. 

In conclusion, I wish to repeat that sectioning of the sympathetic plexus may inter- 
rupt pain either by restoring a better vascularization of a part, or by cutting off fibers 
going into the central nervous system. The paper was a very interesting presentation 
of a field in which clinical practice is in advance of anatomical knowledge. 

DE. BEENAED WIDMAHN. — Of the four cases on whom Dr. Behney did pelvic 
sjunpathectomy, three showed 100 per cent relief of pain. Two of these patients I was 
able to follow for ten days and two weeks respectively. The third patient is still in the 
hospital and is under observation about one month. This case was readmitted to the 
hospital last July with a rectal-vaginal fistula and the pain was so excruciating that a 
quarter of morphine was routinely given morning, afternoon, and evening with only 
partial benefit. Today she no longer has any pain but is still getting a hypodermic at 
night largely because she is a partial addict. There is some pain about the knee joint 
regions, but this appears to be entirely arthritic in character. 

It is interesting to note that in two of these patients, the pain was a deep-seated bor- 
ing pelvic pain described by the patients as being ‘ ‘ deep-do^vn in the bladder. ' ’ 

Obviously some of these patients will not be benefitted by this type of treatment. I 
would, therefore, like to make a point of the character and distribution of pain which 
should be properly evaluated in each individual. Wliether the pain be a so-called sciatic- 
like pain, low back pain, deep-seated pain in the hip joints, or pain reflected down the 
thighs to the knee joints, or a deep-seated pain in the pelvic fossa I think that if the 
character and distribution of the pain could be correlated with the end results of these 
operations that it is entirely possible that the future course of events will enable us to 
establish criteria that will materially aid in selecting the types of eases that should re- 
ceive benefits from pelvic sjanpathectomy. It is well kno-wn that the p.ain may be an 
effect of necrotic tissue rvith an associated reaction to inflammation, or pressure from a 
progressive neoplastic infiltration or even pressure from enlarged iliac or aortic nodes or 
extension along the ureters but there may also be pain from actual bone invasion and 
particularly metastatic infiltrations of a perineural or perivascular character. 

I feel that this form of treatment should receive further investigation along these 
lines and that the results obtained on three out of four eases in our department at the 
Eadium Clinic of the Philadelphia General Hospital justifies the hope that this pro- 
cedure should be effectual for certain characters and distribution of pain which may be 
predetermined by careful studies. 

DE. BEHNEY (concluding). — In reply to Doctor Batson’s question regarding the 
number of times sympathectomy has been done to relieve pain in advanced pelvic car- 
cinoma, I have not found more than fifty cases in the literature which I have covered. 
These operations are not indicated in pain from ureteral obstruction, nor in metastasis, 
if irradiation is effectual. 



PSYCHOGENIC FACTORS IN FUNCTIONAL FEMALE 

DISORDERS^ 

ILvren Hornet, M.D., Chicago, Ile. 

T^ITHIN the last thirty or forty years there has been much discussion 
’ » in the gjmecologie literature on the influence of the psychic factors in 
female disorders. The discrcpanej’- of opinions is as ivide as possible. On 
the one hand there is a tendency to let these factors shrink to a humble in- 
significance. These proponents will emphasize, for instance, that of course 
they see the emotional factors, but consider them dependent on constitu- 
tional, glandular and other bodily conditions. 

On the other hand we see the tendency to ascribe to psychogenic factors a 
very great influence. The supporters of this point of view are inclined to 
see here the essential origin not only for more or less obxdous functional dis- 
orders as pseudocyesis, vaginismus, frigidity, menstruation disorders, 
hyperemesis, etc. But they also claim a psychic influence for those diseases 
and disturbances which seem to be superior to suspicion such as premature 
and postmature delivery, certain forms of metritis, sterility, some forms of 
leueorrhea. 

The fact that physical changes can be brought about by psychic stimuli 
can no longer be doubted since Pavlov has put it on an empirical basis by 
his experiments. "We loiow that by stimulating the appetite the secretion 
of the stomach can be affected, that the heart rhjdhm and the bowel move- 
ments can be accelerated under the influence of fear, that certain vaso- 
motor changes, as for instance, blushing can be an expression of a shame 
reaction. 

We have also a rather exact picture of the ways of transportation on 
which these stimuli are carried from the center nervous system to the 
peripheral organs. 

It seems to be a wide jump from the statement of these rather simple 
connections to such a question as whether a dysmenorrhea can be brought 
about by ps^’^ehic conflicts. Yet I think there is not so much a fundamental 
difference in the process itself, but a fundamental difference in the meth- 
odologic approach. You can arrange an experimental situation where you 
stimulate the appetite of a person and where you can measure the secretion 
of the stomach glands. You can measure exactly the changes in secretion 
which take place when you produce some sort of fright reaction in the 
person, but you cannot arrange an experimental situation where a dys- 
menorrhea is brought about. The emotional proceedings underlying a 
dysmenorrhea are much too complicated to be possiblj’’ established in an 
experimental situation; but even if you could by experiment expose a 

‘Head at a meeting of the Chicago Gynecological Society, November 18, 1932. 

694 



horney: psychogenic factors in febiale disorders 


695 


person to certain very complicated emotional conditions, yon conld not 
expect any concrete results, because a dysmenorrhea is never the result of 
just one emotional conflict situation but always presupposes a series of 
emotional preconditions the foundation of which has been laid at different 
times. 

For these reasons it is impossible to get on with these problems by way 
of experiment. A method which can reveal to us the connection between 
certain emotional forces and a symptom, as for instance dysmenorrhea 
must obviously be a historical one. It must enable us to understand the 
specific emotional structure of a person and the correlation of the emotions 
with the symptom out of a very detailed history of her life. 

There is as far as I see only one psychologic school which offers such an 
insight with a rather high degree of scientific exactness ; namely, psycho- 
analysis. In psychoanalysis you get a picture of the nature, the contents, 
and the dynamic strength of the psychic factors as they are effective in 
real life — a knowledge which is indispensable if one wants to discuss 
scientifically the question whether or not functional disorders can be 
brought about by emotional factors. 

I shall not go into the details of the method here, but shall only present 
in a very concise form some contents of those emotional factors which in 
my analytical work I found essential for the understanding of functional 
female disorders. 

I start with a fact which by its continuous repetition struck my atten- 
tion. My women patients came to be analyzed for the most different 
psychical reasons : states of anxiety of all sorts, compulsion neuroses, de- 
pressions, inhibitions in work and in contact with people, character dif- 
ficulties. As you will find in each neurosis their psychosexual life was 
disturbed. Their relation to men or to children or to botli of them was in 
some way seriously hampered. Wliat struck me was this : among these 
very different types of neuroses there was not one case without some func- 
tional disturbance of their genital system : f rigidity in all degrees, vaginis- 
mus, all sorts of menstruation disorders, pruritus, pains and discharges 
which had no organic basis and which disappeared after uncovering cer- 
tain unconscious conflicts, all sorts of hypochondriacal fears as fears of 
cancer or of not being normal, and some disturbances in pregnancy and 
childbirth which at least seemed suspicious of a psychogenic oiigin. 

Here three questions arise -. 

1. This coincidence of a disturbed psychosexual life on the one hand and 
functional female disorders on the other may be very striking — ^but is this 
coincidence a regular one ? 

An analyst has the advantage of knowing some cases very thoroughly, 
but after all even a busy analyst sees only comparatively few cases. There- 
foi^ even if we find our results corroborated in other observations as well 
as in ethnological facts, this question about the frequency and the validity 



696 


AISIERICAN JOURNAL OP OBSTETRICS ^VND GYNECOLOGY 


of our^ findings is one for which the gjuiecologists should at some future 
date give an answer. 

Of couise, to do tliis, investigation would require from their side time 
and psychological training, but if only part of the energj^ v'hich is put into 
laboratory work would be put into it, it surely would help to clarify the 
problem. 

2. If we assume this coincidence exists regularly: could not both, the 
psyehosexual disturbances and the functional ones, arise on the common 
basis of constitutional or glandular conditions? 

I do not wish to go into a thorough discussion of these very complicated 
problems now, but onl 3 '’ point out that according to my observations there 
is no regular coexistence of these bodily factors and emotional changes. 
There are, for instance, frigid women with distinct masculine attitudes 
and a strong aversion against the female role. Some of them have some 
plij'^sical masculine attributes — ^voiee, hair, bones — ^most of them have, 
however, an absolutelj’- female habitus. With both groups you could find 
out from what conflictful situations the emotional changes started — but 
only in the first gi'oup would it be doubtful whether the conflicts them- 
selves might perhaps have arisen on a constitutional basis. I have the 
impression that as long as we do not Imow more about constitutional factors 
and their particular influence on later attitudes it is pseudoexaetness to 
assume too strict a connection. Furthermore such an assumption may lead 
to very dangerous therapeutic consequences if one neglects the psychical 
factors. For instance, in the most modern German textbook of gynecologj*-, 
Halban and Seitz, one author, hlatthes, describes the following case : a girl 
came to ask his care for a dysmenorrhea which she had had for one and a 
half years. She told him that she had caught a cold on a dancing 
party. Later on he found out that she then had started a sexual relation- 
ship with a man. She told him that she was strongly sexually aroused by 
him but at the same time was enraged at him. As she represented what he 
calls an ‘'intersexual type," he advised her to give up the man, acting on 
the motivation that the types of person to which she belongs never can 
be happy in a sexual relation. She tried to follow his advice and had two 
menstruations without pain. She then took up her love affair and the 
pains 2 ’ecurred. 

This seems to be a rather radical therapeutic conclusion on the basis of 
very slight loiowledge and reminds me of the sajdng in the Bible: "If 
thine eye offend thee, pluck it out. ” 

From the therapeutic point of view it seems better to look on the psychic 
level for the conflicts which may have arisen perhaps from some constitu- 
tional factor particularlj’- as we often see the same conflicts without the 
presence of such a factor. 

3. It is the third question which I wish to discuss now. Its precise 
formulation would be, "Is there a specific correlation between certain 



HORNEY : PSYCHOGENIC FACTORS IN’ FEMALE DISORDERS 


697 


mental attitudes in psyeliosexual life and certain functional genital dis- 
turbances ? ’ ’ Unfortunately human nature is not so simple or our knowl- 
edge not far enough advanced as to enable ns to make very clear and 
rigid statements. In fact you will find certain fundamental conflicts with 
all of these patients which correspond to the fact that you find some de- 
grees of frigidity with all of them — at least a transitional one ; but in a 
regular correlation with certain functional symptoms some specific emo- 
tions and factors play a predominant role. 

With frigidity as the basic disturbance one finds invariably the following 
characteristic mental attitudes : 

In the first place frigid women have a very ambivalent attitude towards 
men. There are always elements of suspicion, hostility and fear in it. 
Very seldom are these elements quite overt. 

For instance, one patient had the conscious conviction that all men were 
criminals and ought to be killed. This conviction was the natural conse- 
quence of her conception of the sexual act which she thought was some- 
thing bloody and painful. She considered every woman who married as a 
heroine. Generally you find this antagonism in a disguised form ; and one 
can get insight into their real attitude towards men, not from their com- 
ments but from their behavior. Girls may tell you franldy how much 
they care for men, how they are inclined to idealize them, but at the same 
time you may see that they are likely to drop their “boy friends” very 
rudely without any apparent reason. To give a typical example from 
many similar ones: I had a patient X who had rather friendly sexual 
relations with men. These never lasted longer than about a year. Eegu- 
larly after a short interval she felt increasingly irritated against the man 
until she could stand it no longer. She then sought and found some 
excuse to drop him. In fact her hostile impulses towards men became 
so strong that she was afraid to do them harm and avoided them. Or 
you may find women who tell you they feel devoted to their husbands 
but a deeper investigation will show you all those small but very disturbing 
signs of hostility which may come out in every day life, such as a funda- 
mental depreciative attitude toward the husband, belittling his merits, 
udthdrawing from his interests or his friends, making too great financial 
claims or waging a quiet but consistent fight for power. 

You can in these cases not only get a more or less distinct impression 
that frigidity is a direct expression of undercurrent streams of hostility, 
but you can also in certain advanced phases of the analysis trace very 
accurately how the frigidity is initiated when a new source of inner aver- 
sion against men is revealed—and how it stops when they have overcome 
these conflicts. 

Here is a marked difference in the psychology of men and of women. In 
the aveiage ease, sexuality in w'omen is much more closely tied up with 
tenderness, with feelings, with affection than in men. An average man. 



698 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


will not be impotent even where he does not feel any particular tenderness 
for the woman. On the contrary there is very often a split between sex 
life and love life which means in the extreme pathologic ease that he can 
only have sex relations with a woman whom he does not care for and that 
he has no sexual desires for and is even impotent towards a woman of 
whom he is really fond. 

With women you will find, on the average, a closer unity between their 
sex feelings and their whole emotional life, probably for obvious biologic 
reasons. Therefore, a secret hostile attitude will express itself very easily 
in the inability of sexual giving and receiving. 

This defense attitude against the man need not be very deeply rooted. 
In such cases a man who is able to awaken their tender feelings may be 
perfectly able to overcome the frigidity ; but in another series of cases this 
attitude of hostile defense is very deep and the roots of it must be exposed 
if the woman is to be rid of it. 

In this second series jmu -will find that the antagonism against the man 
has been acquired in early childhood. To understand the far reaching 
consequences of early experiences in life it is not necessary to Imow much 
about analytical theoiy, but only to be clear on two points : that children 
are already born with sexual feelings and that they can feel very passion- 
ately, very likely much more so than we grown-ups with all our inhibitions. 

You will find in the history of these women that there may be deeply 
engraved disappointnients in their early love life : a father or brother to 
whom they felt tenderly attached and who disappointed them ; or a brother 
who was preferred to them ; or quite a different situation in this specific 
case : when the patient was eleven years old, she had seduced a younger 
brother. Some j’^ears later this brother died from the grippe. She had im- 
mense guilty feelings. Still after thirty years, when she came to be ana- 
lyzed, she felt convinced that she had caused the brother’s death. She be- 
lieved that in consequence of her seduction her brother had started to 
masturbate and his death had been the consequence of his masturbation. 
This guilty feeling made her hate her own female role. She wanted to be 
a man, rather demonstratively envied men, let them down wherever she 
could, had fierce castration dreams and fantasies and was absolutely frigid. 

This case, by the way, throws some light on the psychogenesis of vagi- 
nismus. She was not deflorated until four weeks after her marriage and 
even then it was done by a surgeon, though no abnormality in her hymen 
existed and though the man was potent. The spasm was partly an expres- 
sion of her strong aversion against the female role, partly a defense mech- 
anism against her castration impulses toward the envied man. 

This aversion against the female role often exerts a great influence how- 
ever it may have started. In one case there was a younger brother who 
was preferred by both parents. The envy towards him poisoned her whole 
life and pai’tieularly her relations to men. She wanted to be a man her- 



HORNBY: PSYCHOGENIC FACTORS IN BEMALE DISORDERS 


699 


self and played this role in fantasies and dreams. During; intercourse she 
sometimes had quite consciously the wish to change the sex roles. 

Now you will find in these frigid women another conflict situation often 
dynamically still more important: that is the conflict with the mother or 
with an older sister. Consciously the feeling toward the mother may he 
different. Sometimes they admit at the beginning— even to themselves— 
only the positive side of their relation. Possibly they have already felt 
struck by the observation that in spite of their craving for the mother’s 
love, they have in fact always done just the eontrary of what the mother 
would have liked them to do. In other eases there is an overt hatred. But 
even if they realize the existence of a conflict, they will know neither the 
essential reasons for it nor the influence it has on their psychosexual life. 
One of these essential features may be for instance that the mother keeps on 
representing for these women the agency which is forbidding sex life and 
sex pleasure. An ethnologist recently told the following custom of a prim- 
itive tribe which throws light on the ubiquity of these conflicts: when 
the father dies, the daughters remain in the house of the deceased, but the 
sons leave it, because they fear that his spirit might be hostile to them and 
do them harm. When the mother dies, the sons remain in the house, but 
the daughters leave it for fear that a spirit of the mother might, kill them. 
The same antagonism and retaliation fear which has found here such a 
clear expression wiU regularly be seen in the analysis of frigid women. 

Here one who does not know the process of analysis may ask : if these 
conflicts are not conscious to the patients, how can you pretend so definitely 
that they exist and that they play this particular role ? There is an answer 
to this question which however may be difficult to understand for someone 
lacking the analytical experience. These older irrational attitudes are 
revived and reactivated towards the analyst. For instance, the patient X 
had consciously an affectionate attitude to me, though always intermingled 
with some fear ; but at the time when her old infantile hatred against her 
mother came nearer to the surface, she trembled for fear in the waiting 
room and emotionallj’- saw in me something like a ruthless evil spirit. 
From many detailed traits it became evident that in these situations she 
had transferred an old fear of the mother to me. One particular incident 
gave us the insight into the important part this fear of the forbidding 
mother played for her frigidity. At a period in the analysis when her 
sexual inhibitions had already diminished I was away for a fortnight. She 
told me afterwards that one evening she had been together with some 
f 1 iends and that she had drunk some alcohol but not more than she could 
ordinal ily toleiate and that she had no memory of what happened after- 
wards. But her boy friend had told her that she had been very excited, 
herself asked for intercourse and that she had had a full orgasm— she was 
completely frigid until then — and that she had exclaimed several times 
in a sort of triumphant voice, ‘ ‘ I have Homey holidays. ’ ’ The forbidding 



700 


AMERICAN JOURNAL OF OBSTETRICS AND GTNECOLOGT 


mother role which I took in her fantasy was absent and therefore she could 
be a loving woman without fear. 

Another patient with a vaginismus and a later frigidity had transferred 
to me the old fear she had towards the mother and particularly towards 
the sister eight years older. She made several attempts to make contacts 
with a man but always failed on account of her own complexes. Regularly 
in such situations she would feel infuidated against me and even some- 
times express the rather paranoid fear that I had kept the man away from 
her. Though she realized intellectually that I was the one who wanted 
to help her to find adjustment, the old fear of the sister then had the upper 
hand. And at the time when she had had her first sexual experience with 
a man she promptly had an anxiety dream in which her sister chased her 
around. 

There are in ever}’’ case of frigidity other psychical factors involved, 
some of which I shall now mention. But I shall neglect the connection 
these have with frigidity and onlj’- point out tlie importance they may have 
for certain other functional disorders. 

There is above all the influence which masturbation fears may exert on 
mental attitudes as well as on bodily processes. 

It is well know that on the basis of such fears concerning masturbation 
nearly every disease may be regarded as a resultant from it. The partic- 
ular form these fears often take with women is the fear that the genital 
organs are physically damaged by masturbation. This fear is often con- 
nected with a very fantastic idea that they once have been like a boy and 
have been castrated. Such a fear may express itself in different forms. 

1. In a vague but deep fear of not being “normal. ' ’ 

2. In hypochondriacal fears and symptoms such as pains and discharges 
without an organic basis which drives them to seek g 3 Tiecologic advice. 
They then will get a suggesth'e treatment or some sort of reassurance 
and will feel better — but naturally the fear starts again and they return 
with the same complaints. Sometimes this fear leads them to insist upon 
an operation. They have the feeling that something is physically wrong 
with them and can only by an operation be radically changed. 

3. The fears may furthermore take this form : because I have damaged 
myself, I shall never be able to get a child. In very young girls this fear 
in this very connection may be sometimes quite conscious. But even these 
young patients usually will tell you first that they consider having children 
disgusting and never wish to have an 3 ^ Only much later you hear this 
feeling of disgust represents for them a kind of “sour grapes” reaction 
against their very intense earlier wishes for having many children and 
that the above-mentioned fear has led them to deny this wish. 

There may be many conflicting unconscious tendencies connected with 
the wish for a child. The natural maternal instinct may be counteracted 
by certain unconscious motives. I cannot go into details now and shall 



HORNEY: PSYCHOGENIC FACTORS IN PESIALE DISORDERS 


701 


only mention one possibility ; foi* tliose women wlio in some part of their 
mind have an intense wish to be a man, pregnancy and motherhood as 
representing the equivalent female accomplishment has an enhanced 
significance. 

I have nnfortnnately never seen a case of psendocyesis, but probably it 
too results from unconscious reenforcement of the wish for a child. 

Certainly a temporary amenorrhea will favor these wishes to have a 
child at any price. Every gynecologist knows women who are unusually 
nervous and depressed, but are perfectly happy and poised as long as 
they are pregnant. For them too pregnancy represents a particular form 
of satisfaction. 

What is reenforced in the cases I have in mind is not so much the idea of 
having a child, nursing and caressing it, but the idea of pregnancy itself ; 
of bearing the child in their body. The state of pregnancy has for them 
an exquisite narcissistic value. Two such eases had a postmature delivery. 
It is premature to draw any conclusions, but with all critical cautiousness 
one could at least think here of the possibility that the unconscious wish 
of keeping the child within might be an explanation for some cases of 
postmature delivery which are otherwise inexplicable. 

Another factor which surely sometimes plays a r61e is an intense fear of 
dying at delivery. This fear itself may or may not be conscious. The real 
origin of the fear is never conscious. One essential element in it is, ac- 
cording to my experience, an old antagonism against the pregnant mother. 
One patient I have in mind who had an extreme fear of dying in childbirth 
remembered that she had as a child for many years anxiously watched 
her mother to see if she was pregnant again. She never could see a preg- 
nant woman on the street without feeling the impulse to kick her against 
the womb and naturally had the retaliation fear that something equally 
awful would happen to her. 

On the other hand the maternal instinct may be counteracted by un- 
conscious hostile impulses against the child. Here very interesting prob- 
lems are the possible influence of such impulses on hj’peremesis, premature 
delivery and depressions after childbirth. 

To go back once more to the masturbation fears, I have already men- 
tioned that they might result in the idea of the patient being physically 
damaged and that this fear might lead to hyperchondriacal symptoms. 
There is another way in which these may be expressed : in the attitude 
towards menstruation. The idea of being damaged makes them resent 
their o^vn genitals as a sort of wound and menstruation is emotionally 
conceived as a corroboration of this assumption. They have kept a close 
association between bleeding and a wound. It is understandable from this 
that for these women, menstruation can never be a natural process, but 
that they will have a deep disgust reaction against it. This leads me to the 
problem of menorrhagia and dysmenorrhea. Of course, I am only speak- 



702 


AjNIERICAN jourkal op obstetrics and gynecology 


iiig of those forms in which there is neither any local nor other organic 
cause. The basis for an understanding of any functional menstrual dis- 
order is this ; the psychical equivalent of the bodily processes in the geni- 
tal organs at that time is increased libidinal tension. A woman who is 
very poised in her psychosexual development will meet this without any 
particular difficulties. But there are many women who just succeed in 
maintaining some sort of balance and for whom this increased libidinal 
tension is the straw which breaks the camel’s back. 

Under the pressure of this tension all sorts of infantile fantasies will be 
revived ; particularly tliose wliich have some connection with the process 
of bleeding. These fantasies have, generally spealdng, the content that 
the sex act is something cruel, bloody, and painful. I found without any 
exception that fantasies of this kind played a determining role in all pa- 
tients udth menorrhagia and dj^smenorrhea. The dysmenori'hea usually 
starts if not in puberty at the time when the patient comes in contact with 
adult sex problems. 

I shall tiy to give some examples: one patient of mine who suffered 
from a profuse menorrhagia always when thinldng of intercourse had a 
vision of blood. One line which led up to it had to do with certain child- 
hood memories. 

She was the oldest of eight children and her most frightening memories 
concerned the time when a new child Avas born. She then had heard the 
mother scream and had seen bowls of blood carried out of her mother’s 
room. The eai’lj^ association betiveen childbirth, sex, and blood was so 
close for her that one night when the mother had a lung hemorrhage, she 
immediately connected it Avith the marital relations of her parents. 

Her menstruation reAUved for her these old infantile impressions and 
fantasies of a Amry bloody sex life. 

The patient AAdiom I have already mentioned had a seA^ere dysmenor- 
rhea. She herself AA'^as perfectly aAvare that her real sex life had to do 
with all sorts of sadistic fantasies. Whenever she heard or read of cruel- 
ties, she felt sexually aroused. She described the pains Avhich she had at 
the menstruation time as if her insides were torn out. This specific form 
Avas determined by infantile fantasies. She remembered haAdng had as 
a small girl the idea that in intercourse the man tore out something from 
the body of the woman. In the dysmenori’hea she emotionally acted out 
these old fantasies. 

I suppose that a great maiy of my statements eonceiming the psycho- 
genic factors may sound utterly fantastic, though perhaps all this is not 
really fantastic but only foreign to our usual medical thinldng. If one 
AAushes to have more than a mere emotional judgment, there is only one 
way scientifically Amlid : a testing of the facts. The fact that we can cure 
these symptoms by uncovering their specific psj^chical roots is no scientific 
proof. Any skillful suggestion ma3’’ eAmntuallj'' have the same result. 



703 


HOPNEY: PSYCHOGENIC EACTOKS IN EEMALE DISORDEES 

The scientific way of testing onght to be the same here as in other fields 
of seienee; to apply the same method, the psychoanalytical technic of 
free association, and see if the findings are similar. Every judgment which 
has not met this requirement lacks scientific value. 

Yet it seems to me that there is still another way for the gjmeeologist to 
get at least a feeling of evidence for the specific correlation of certain 
emotional factors and certain functional disturbances. If only some time 
and attention would be given to the patients, at least some of them would 
reveal their conflicts very easily. I think this way of proceeding might 
even have some direct therapeutic value. A correct analysis can only be 
done by a physician who has had an adequate psychoanalytic training. It 
is a procedure not less incisive than an operation. Yet there is not only 
a major but also a minor surgery. A minor psychotherapy would consist 
in dealing with the more recent conflicts and uncovering their connection 
with the symptoms. The work which is already being done in this way 
could easily be very greatly extended. 

There is only one limitation to such a possibility which one has to realize : 
one must have a rather thorough psychologic knowledge if one wishes to 
avoid mistakes; particularly those which may stir up emotions with which 
one is not able to cope. 

DISCUSSION 

DE. A. G. GABEIELIANZ. — The paper was timely. The gynecologist besides in- 
serting his two fingers into the vagina must very delicately insert liis two fingers also 
into the soul of the women. Constitutional pathology exists and interrelation between 
woman’s disorders and her constitution is marked in many cases. This interrelation- 
ship as well as the correct secretion of her internal glands has a great influence on the 
psyche of women. The hypersecretion of corpus luteum leads women to neuropsychical 
weakness. Some eases are so striking that they may require consultation with psychi- 
atrists. Hyperovarianism increases the individuality of Avomen, makes them more im- 
pressible; they become talented, voluptuous and some practice masturbation. Hypo- 
ovarianism leads to psychic and somatic slothfulness and frigidity. In the biologic test 
there is absence of anterior pituitary and ovarian sex hormone in the blood and in the 
urine. 

DB. "WILLIAM H. EUBOVITS. — One statement which Dr. Homey made should 
be emphasized before a body of gynecologists. Namely, that “of course there are 
exceptions.” I think, vicAving the subject dispassionately, one must evaluate the 
opinions of the psychoanalysts who believe that many of the activities of the human 
body, more particularly functional activities, may be regulated under the guidance of 
psyclioanalysis. On the other hand, most of the gynecologists and surgeons believe that 
very little can be accomplished by psychoanalysis, I believe the essence of the matter 
lies somewhere between the tAvo extreme views and that much good can be accomplished 
by cooperation among those who have intelligent yet opposite vicaa’s. 

Wlien I come on scrA-ice in the Gynecological Department of the hospital I find it 
necessary to dismiss about 25 per cent of the patients Avho are sent from the clinic to 
the hospital for operation, because after many years’ observation I hUA’c been con- 
vinced that whereas many of these p.atients display certain gjuiccologic and pathologic 
findings, operative interference would not benefit them sufficiently to warrant surgical 



704 


AJIERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGT 


methods. I merely am impressed with the fact that the variety of complaints ex- 
tended over such a rvide field that nothing wo could do surgically could possibly cure 
some of these patients, I would like to mention briefly a number of experiences to 
illustrate the statements I have just made. 

One patient who was sent into the medical ward was referred to the gynecologic de- 
partment for operation and, although she possessed a fibrotie uterus with some menor- 
rhagia and metrorrhagia and although she had numerous abortions performed and 
lived in constant fear of becoming pregnant, her nervousness appeared to me to be her 
chief complaint. After a consultation between the psychiatrist and the internist I was 
persuaded to perform a hysterectomy on this patient, which I did reluctantly. Since 
the operation was performed this patient has acquired many new phobias to replace 
those which wo may have eliminated for her. I am sure this patient should have re- 
mained in the hands of the medical man and the psychiatrist. 

The only time I found myself solely responsible for that kind of management was 
when a very reputable medical man referred a patient to me for some plastic work and 
I agreed also to sterilize her. I saw her only once and did the operation. Several days 
later I had a letter from a brother of the patient calling all'the curses imaginable down 
on me for having performed the operation. His doctor in Liverpool informed me the 
whole family was crazy and this patient is now in an asylum. 

There is no question, to my mind, but that we must fall back on the psychiatrist and 
psychoanalyst for help in many of these cases. Early in my career I am sure I per- 
formed the Dudley operation for anteflexion, the Gilliam ventrosuspension, dilatation 
and curettage far too often and in recent years I have very liberally used the sex 
hormones in cases of functional menstrual disturbances with no success whatsoever. 
I have been gratified by the help that I have been able to find from the psj’chiatrist and 
from the psychoanalyst. 

Again, a patient in apparently perfect health wanted to get married but said she 
could not until her enuresis was cured. After careful gjmecologic examination and 
careful study of her history I could elicit nothing wliich would respond to gynecologic 
treatment. This patient was treated by the psychiatrist and is cured and married. 

Another patient whose only symptom vras an intolerable pruritus vulvae, gave a 
very detailed history and displayed the scars of several operations and said she had 
been treated by every type of medieal specialist except a psychiatrist. I, therefore, 
directed her to a well knoivn psychiatrist and she is apparently cured. 

Therefore, in conclusion, I would like to say that if we carefully evaluate*and clearly 
interpret the gynecologic cases that come to ns, of course making as certain as we can 
by every diagnostic method at our disposal that no gynecologic pathology exists, that in 
this large group of functional cases cooperation between the gynecologist, psychiatrist, 
and psychoanalyst will prove of benefit to the patient. 



THE IRREGULARITY OF THE MENSTRUAL FUNCTION* 
Edward Allen, M.D., Chicago, III. 

V 

^ (From the Fresbyterian Sospital) 

^''^^HE regularity of the menstrual function has been almost universally 

accepted by doctors, research workers, and lay people as a criterion of 
normality. Deviations from this rhythmic habit of any degree are inter- 
preted as ewdences of numerous pathologic conditions. Statistics a'nd ob- 
servations based upon statements from individuals who consider them- 
selves normal and therefore believe that they are absolutely regular in 
their menstrual function have resulted in our present accepted opinion of 
menstrual periodieityv^ 

One lias only to practice obstetrics a short time to realize how inaccurate the ordi- 
nary patient can be about her menstrual periods. Yet almost all of the statistical 
studies of the menstrual periodicity are founded on the observations of the patients 
themselves. When pregnancy is either^reatly feared or greatly desired there is no 
possible greater incentive for accuracy. Kelly,’ in 1908, states that in 1000 cases, 942 
reported a twenty-eight day interval and 22, a twenty-one day interval. This leaves 
only 36 patients who menstruated irregularly. In 1916 Sanes' reported an analysis 
of 4500 records and found that 75 peif cent of the patients menstruated regularly. 
Seventy-two per cent of these were of the twenty-eight day type. Heyn’ studied 1684 
eases and found that 63.5 per cent were of the accepted twenty-eight day interval, 10.9 
per cent menstruated every twenty-one days while 14.1 per cent varied from three to 
four weeks. Webster,’ of this Society, says in his textbook that in about 86 per cent 
the menstrual type is regular. He allows 71 per cent for the twenty-eight day type;, 
14 per cent for the thirty day type, and states that the twenty-one day type is also 
found. He adds that a few other variations are found. Graves^ in his recent (1929) 
textbook says, ‘ ‘ Ideally the menstrual rhythm should be established quickly at inter- 
vals of twenty-eight days, -though twenty-seven and thirty-one are within normal 
limits. ” Geist® in a study of 200 patients and a few female workers found a marked ir- 
regularity in their menstrual cycles. There was an eighteen to sixty day variation in 
the intervals between periods and the length of the flow was from twelve hours to eight 
days. Also the character of onset of the bleeding and the amount of blood lost were 
quite variable. 

Bartelmez” has found definite evidence in his cytologic w-ork on the cyclic phenomena 
in the human endometrium that would indicate that the process is quite irregular. 
Uteri removed at various stages of the menstrual interval did not always correspond 
with the stage of activity one would expect to find at that time. \/ 

Our attention was called to the absolute irregularity of the menstrual 
function during a study^® of the blood calcium levels between and during 
the menstrual flow. At the time we called for volunteers from the nursing 
school asking for those who were absolutely regular in their menstrual 
function. Those that responded stated that they were ‘ ‘ as regular as clock 
wozlv, absolutely regular,” or “menstruated on a eei'tain day of each 
month. The periods which occurred during this observation varied from 

•Read before the Chicaeo Gynecological Society, June 17, 1932. 

705 



706 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


five to twenty days. Similar observations in the literature led us to study 
larger group in tlie same way. 

Foster,® in 1889, reported to the New York Medical Society accurate observa- 
tions covering 380 menstrual periods occurring in fifty-six normal women. He found 


that only forty-five of these 380 periods occurred at an interval of twenty-eight days, 
225 were shorter and 110 longer. The extremes were forty-sLx to sixteen days. Only 
one case exhibited a perfect regularity and that was at intervals of twenty-sLx days. 
The members of the society, in discussion, all thought that such irregularity must be due 
to some pathologic yondition. Jessie L. King" found even a wider variation in rhythm 
after making a survey of 13 subjects during a study of the vaginal cycle, during which 
smears were taken every day. The interval in this series of 523 menstrual periods 
varied from eighteen to fifty-three days. None were regular. The majority of the pe- 
riods, however, occurred between the twenty-second and the thirty-sixth day. \/C 



Table I 



ACCURATE 

QUESTIONABLE 

Total Number of Cases 

110' 

21 

Number of Periods 

1291 

231 

Number of Individuals Sliowing 
Absolute Eegularity 

0 

0 

Number of Individuals Showing 
Absolute Irregularity 

30 

14 

Variations in Interval 

13 to 84 days 

11 to 72 days 

Duration of Periods 

12 = 3 to 5 days 

21 = 4 to 5 days 

20 = 4 to 6 days 

8 = 4 to 8 days 

11 = 5 to 6 days 

9 = 5 to 7 days 

6 = 5 to 8 days 

2 = 3 to 5 days 

1 4 = 4 to 6 days 

1 = 4 to 8 days 

2 = 5 to 6 days 

3 = 5 to 7 days 

3 = 6 to 7 days 

Number of Pads Used 

50 = 6 to 12 

60 = 12 to 30 

10 = 6 to 12 

11 = 12 to 30 

Pain 

Irregular =37 
Constant =23 

None = 50 

Irregular = 6 
Constant = 4 

None = 11 


The data included in this report were collected from the menstrual rec- 
ords of 131 members of a Nurses’ Training School. '^One hundred ten of 
these eases were accurately controlled. The remaining 21 were open to a 
little question, but since the results are so nearly alike we have included 
them under a separate heading. ' 

v^In all 1522 menstrual periods are recorded, 1414 in the controlled group 
and 231 in the questionable. ^,At the onset of the period of observation the 
subjects were told the purpose and general plan of procedure, impressing 
upon them the value of accuracy and insisting that we would rather not 
have their records included if not certain of absolute accuracy. At this 
time they were asked to fill out a questionnaire. This questionnaire cov- 



ALLEN: IRREGULARITY OF MENSTRUAL FUNCTION 
Table II. Menstrual Intervals of Typical Sub.iects 


707 


A 

B 

C 

D 

E 

F 


31 

27 

39 

25 

23 

32 


23 

374 

27 

25 

27 

32 


29 

33 

47 

26 

22 

21 


29 

35 

25 

24 

28 

36 


OO 

32 

23 

20 

25 

27 


37 

85 

28 

54 

22 

41 


23 

31 

49 

42 

31 

32 


27 

35 

24 

25 

27 

30 


28 

30 

21 

29 

45 

30 


23 

23 

29 

25 

32 

28 


21 

30 

34 

30 

27 

31 


24 

29 

25 

16 

25 

35 


24 

27 

27 

25 

51 

26 


25 

31 

26 

22 

28 

37 


26 

26 

29 

27 

19 

26 


55 

29 

26 

25 

28 

35 


22 

29 

27 

24 

24 

27 


21 

27 




26 


23 

33 




31 


27 

27 




24 


25 

26 




33 


26 

25 




36 


16 

27 






25 

28 

27 

23 

21 

28 



eved their impressions of their menstrual habit during the last five years. 
The questions asked were : 

Have you menstruated ■with absolute regularity? Wliat is the average duration, 
number of pads used, and arc the periods associated ivith pain? 

The school nurse of the home then began to cheek the menstrual periods. 
It entailed a tremendous amount of work and patience, and these results 
would not have been possible without her earnest cooperation. Slips were 
handed to her each month containing the data of that particular period. If 
reports were not in on the expected day a daily check was made until they 
were forthcoming. These slips were then transferred to a permanent cal- 
endar record. 

The most striking fact gleaned from the above study is the marked ir- 


Table III. Analysis op 1522 Intervals 


accurate 


QUESTIONABLE 


2 — 17 days 

61—29 

2 — 18 days 

60—30 

9 — 20 days 

50—31 

8 — 21 days 

20—32 

10 — 22 days 

15—33 

15—23 days 

13—34 

28 — 24 days 

5 — 35 

46 — 25 days 

8—36 

37 — 26 days 

4—37 

55 — 27 days 

4—39 

55 — 28 days 

4—40 


days 

4 — 30 days 

days 

4 — ^28 days 

days 

2 — 27 days 

days 

2 — 29 days 

days 

2 — 35 days 

days 

days 


days 


days 


days 


days 




708 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


regularity of the whole process. Even among the 87 who thought in the 
beginning that they ivere absolutely regular, irregularity in inteiwal, num- 
ber of pads used and the length of the flow were very marked. Fifty-three 
of the group recognized that they were somewhat irregular but even they 
were surprised by the arrhythmia, of the cycle. 

During the period of observation records were kept as to the sort of duty 
the individual was performing during each month and period. Variation 
in occupation did not seem to appreciably affect the general cycle or vary 
the amount of dysmenorrhea, mth the exception of duty in the general diet 

Table Menstrual Record of V. W. 


Time Studied; October, 1929, to October, 1931. 

Total Number of Periods = 25 

Pain: 15th period Senior duty second upper 
17th period C Floor — day dut}- 
20th period Operating Room 

Number of pads used; 4-4-4-4-4-5-5-6-4-4-4-3-0-3-5-4-4-4-4-5-4-5-3-5 
Number of days in period: 3I-4-4-4-3-5-5-5-4-4-4-1-5-4-5-4-4-4-4-5-4-4-5-5 
Intervals: 27-374-33-35-32-35-31-35-30-28-30-29-27-31-26-29-29-27-33-27-26-25-27 
ffistory of pain ; Yes 

History of regular intervals: Yes, every 28 days “unless chilled or had wet feet.” 


kitchen or the drug room where stepping into the large refrigerators in each 
place seemed to increase the amount of pain during such duty. Outside of 
this fact the reasons given to explain the irregularities were of no apparent 
importance. Forty-three of these 131 young women complained of pain of 
varjdng degree with every period, 48 had discomfort at irregular times and 
55 had no discomfort worth mentioning. 

If under regulated conditions these normal healthy young women have 
such marked variability in the menstrual function, then surely we must 
conclude that the same will hold true for normal Svomen anywhere and that 
we should abandon our ideas that normally the periods are regular and 
usually at intervals of twenty-eight days. 

REFERENCES 


(1) Kelly, E. A.; Medical Gynecology, 1908. (2) Sanes, K. I.: Am. J. (^st. & 
Dis. of Women & Child. 73: 93, 1916. (3) Eeyn, A.: Ztschr. f. Geburtsh. u. Gynak. 

82: 136-152. (4) Welster, C.; Diseases of Women, 1907. W 

Textbook of Gynecology, 1929. (6) Foster, F. P.: New York M. J. 49: 610, 1889. 

(7) Kinff, J. L.: Pub 363 Carnegie Inst., 79r94. {B) Geist, S. E.: Am. J. Obst. A 

Gtneo. 20: 320, 1930. (9) Bartelmes, G. W.: Am. J. Obst. & Gyneu 21: ^23, 1931. 

(10) Allen, Edward, and Goldtliorpe, E. G.: Am. J. Obst. & Gtneo. It: i89, 1929. 

55 East Washington Street. \J 


ABSTRACT OF DISCUSSION 

DR. GEORGE W. BAETELMEZ.— Dr. Carl Hartman has pointed out that the 
threshold for bleeding has become very low in the uterus, espeeiallj in primates an t 






ALLEN; IRREGULARITY OP MENSTRUAL FUNCTION 


709 


is an adaptation, for providing tlie implanted egg with hlood. In tins connection I 
would say that normally there are varions conditions which bring about extravasation 
in the uterine mucosa. The most important bleeding is that which follows implanta- 
■(jjoxi — the "placental sign" of Long and Evans. It is part of the cj’clic ovulation 
implantation mechanism. When the conditions are optimal we get (in the absence of 
fertilization) the typical pseudopregnancy which Schroeder, hleyer and others regard 
as the only normal type of cycle. This involves the maturation and rupture of a graafian 
follicle, corpus luteuiu formation with the associated uterine developments and after a 
more or less definite interval, the extr.avasation of blood. Frequently, however, the 
stimulus is not adequate to produce ovulation but there is nevertheless a certain amount 
of uterine development and eventually menstruation occurs. At other times there is 
little or no ovarian or uterine development but stiU bleeding occurs at the c.xpectcd time. 
Finally, the stimulus may be below the threshold even for extravasation and a period 
is missed. There are, in other words, many transitions between optimal and subminimal 
conditions. 

If this interpretation of the situation be correct, then the attack on the physiology 
of menstruation should begin noth a study of the factors concerned in the implantation 
hemorrhage which is not confined to primates and probably occurs in all mammals. The 
recent experimental studies on the physiology of menstruation have only demonstrated 
that a variety of difCercnt conditions can produce the essential features of menstrua- 
tion, i. e., extravasation of blood and some necrosis. I believe we shall make more 
progress by first establishing the normal sequence of events during menstruation and 
then by finding out what hormones are active or activated normally just before and 
during menstruation. 

DE. JOSEPH BAER. — In the analysis of the data gathered by Dr. Allen, I am 
wondering whether he studied the number of periods in a given time interval per in- 
dividual, For example, in a calendar year would the given young woman who thought 
she was accurate have twelve menstrual periods or perhaps thirteen, one a little more 
than twenty-eight days and the next at a little less than twenty-eight days but striking 
an approximate average of twenty-eight days. 

I believe that the material used is not ideal. Nurses in training schools of hospitals 
are living under more or less artificial environment, both as to daily occupation and as 
to their surroundings. It occurred to me, having seen many nurses who have long pe- 
riods of amenorrhea, whether it would not be well to carry on this investigation with a 
different type of individual, preferably the young woman in her o^vn home, living what 
we would consider as nearly normal a type of existence as can be obtained in modern 
life. 

"^DR. N. SPROAT HEANEY. — After a study of a considerable amount of material 
over a long period of time, I have come to the conclusion that absolute regularity is 
rarely met with and that the patient who menstruates like clockwork is usually mistaken, t/ 

DR. ALLEN (closing).— I have not analyzed these histories with the idea of 
whether or not there were twelve periods in a year. My general impression is that it 
would average about that. However, some menstruated at seventeen days and then 
jumped to forty, which might cut down the periods in the year. 

I think the term regular irregularity would be better than irregular regularity. 

Only a few times in studying any case did the patient menstruate at twenty-nine, 
twenty-eight or twenty-six days; therefore, I think the term regular irregularity would 
be more appropriate. 

We felt that these young women were living, perhaps, under more normal routine 
than the ordinary patient we see in the oifice. The fact that they were on duty did not 
seem to have any appreciable effect. It seemed to me that conditions were as normal 
as we could find in any group of women. 



DIABETES AND PREGNANCY® 


Joshua Ronsheim, M.D., Brooklyn, N. Y. 
(From the Service of the Jcioish Hospital) 


'T'HE cases of diabetes and pregnancy with wbicli we are confronted 
from time to time may be divided into three gi-onps ; first, the diabetic 
who becomes pregnant ; second, the pregnant woman who develops dia- 
betes ; third, the pregnant woman who at no time shows any evidence of 
diabetes bnt in whom, after a catastrophe has beset the pregnancy, e\d- 
dence of a latent diabetes is established by her response to the sugar tol- 
erance test. We are not concerned here witli those eases in which, during 
pregnancy, lactose appears in the urine nor those in which in spite of the 
appearance of glucose in the urdne, the blood sugar remains constantly at 
noirmal levels ; these latter cases are the so-called renal diabetes ; they are 
cases of low. sugar threshold and can be controlled by regulating the carbo- 
lij’^drate intake. Following are examples of the three tj^pes of cases. 


Case 1. — (No. 144926) Aged twenty-three; came to the prenatal clinic on Nov. 24, 
1931, in her second pregnancy, the first having been terminated a year previously by 
therapeutic abortion. Three years prior to her visit there had been a gradual onset 
of all the symptoms of diabetes including a loss of fifty pounds in two years. Last 
menses began May 1. Urine showed 3.3 per cent sugar. Hospital observation was 
advised and six days later she was admitted to the medical service. She now had 3 
per cent sugar in the urine with acetone and diaeetic acid; blood sugar 278 mg. per 
100 c.e. ; blood chemistry otherwise negative. Under dietary regulation and insulin 
her condition improved insofar as the urine was concerned but the blood sugar remained 
high, being 250 mg. on December 3 and 300 mg. on December 8. On December 10 she 
was discharged from the hospital and readmitted two days later to the obstetric serv- 
ice, in labor, with membranes ruptured and a breech presenting. After a labor of 
about ten hours ’ duration, during which time the fetal heart disappeared, she was de- 
livered of a stillborn premature female infant weighing 5 pounds 6 ounces. Since 
her discharge from the hospital she has been under the care of the diabetic clinic 
where, in spite of her lack of cooperation, she has gained some weight and the insulin 
has been reduced to 15 U twice daily. Her urine varies from sugar free to 2.7 per 
cent depending on her adherence or nonadherence to instructions. 

Case 2. — -(No. 81469) Aged twenty-nine, came under my care on Sept. 29, 1923. 
She was in the last month of her third pregnancy. Her first pregnancy occurred three 
years before and was terminated by a forceps delivery resulting in a stillbirth. Wheth- 
er this fetus was alive at the time of the instrumentation cannot be ascertained. She 
did not admit having been pregnant again until the present pregnancy but after her 
delivery she confessed to having had a five-month miscarriage one year after the first 
birth. Two days after her first visit to the oifice, at which time nothing unusual was 
found, she reported absence of fetal movements and examination confirmed the death 
of the fetus in utero. Sixteen days later she had a spontaneous delivery of a macerated 
fetus weighing 8 pounds 6 ounces. Several examinations of the urine prior to delivery 
were normal but on admission to the hospital blood sugar was 230 mg. and a few days 


‘Read, by invitation, at a meeting 
tober 11, 1932. 


of the New York Obstetrical Society, Oc 
710 



RONSHEIJl: DIABETES AND PREGNANCY 


711 


later sugar appeared in the urine. Under dietary regulation and insulin the urine be- 
came sugar free and the blood sugar returned to normal. 

Case S. — (No. 25251) Aged thirty-one. Her first pregnancy, so far as can be de- 
termined, ran a normal course; labor occurred a few weeks premature and the baby 
died on the eighteenth day in deep jaundice. Fifteen months later a second pregnancy 
terminated in a premature birth; this child is living but is mentally defective. The 
present pregnancy began Jan. 11, 1932 ; the course was entirely uneventful, repeated 
urinary examinations and blood pressure readings being normal. However, on August 
8, about ten weeks before term labor set in, a premature female of three pounds was 
born spontaneously and died within twenty-four hours. All investigations were nor- 
mal but the glucose tolerance test done several days postpartum gave the following 
results : 

Before ingestion blood sugar 107.1 mg. urine negative 

1 hour later blood sugar 233.1 mg. urine negative 

2 hours later blood sugar 214.3 mg. urine negative 

3 hours later blood sugar 196.4 mg. urine negative 


In the first case presented, we were dealing with a severe type of antegestational 
diabetes in a noncooperative patient who presented herself too late to be really helped; 
the second is a case of mild diabetes developing during pregnancy; with an honest 
history and earlier investigation the child might have been saved. The third case 
is one which may properly be called latent diabetes ; her mother has diabetes and she 
will no doubt eventually become a frank diabetic. 


Up to the time of the mtvoduetioii of hisulin in the treatment of diabetes 
not more than 5 per cent of these women became pregnant ; since then this 
percentage has probably been raised. "Wben pregnancy does occur it 
should be considered as a serious complication since the disease will be ag- 
gravated by the pregnancj'' and the patients, as a rule, are difficult to con- 
trol. Some of our patients make only one visit to the clinic or present them- 
selves only after fetal death has occurred ; others, while regular in their 
visits are not cooperative in the management of the diabetes. On the other 
hand the pregnant woman in whom diabetes develops is rarely in danger 
(unless it be a fulminating type) because tbe onset is usually in the latter 
months and slow. It is, however, a real menace to the unborn child because 
its presence is usually unsuspected or undiscovered until miscarriage or 


premature birth of a baby that succumbs in a few hours to days takes place, 
or the patient goes to terra but the evidences of fetal life disappear a few 
weeks previously. The diagnosis is dependent upon careful, frequent ex- 
aminations of the urine and, more particularly, periodic determinations of 
the blood sugar. The latter is especially irapoi-tant in the patient who has a 


family history of diabetes, or the patient who has had previous miscar- 
riages or stillbirths which canuot be satisfactorily explained. Elimination 
of the diagnosis of diabetes on urine examination alone is fraught with 
danger since the patient may have a high sugar threshold. The opposite is 
also true ; sugar in the urine does not necessarily spell diabetes. 

Slaternal mortality before the days of insulin vained from 15 per cent to 
30 per cent during pregnancy, labor, and the puerperium, with an addi- 
tional 10 to 20 per cent, dying within the year following of diabetes or tu- 
berculosis. A much higher mortality was reported by Offergeld who, in 



712 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


1909, collected 57 cases of which 80 per cent died in coma during labor or 
the puerperium or within fourteen months thereafter. Since the introduc- 
tion of insulin this mortality has been definitely lowered. Whether' the 
pancreatic activity of the fetus is of value in the control of diabetes in the 
mother is questionable; the experiments of Carlson and his coworkers 
have been refuted by Markowitz and Soskin as recently as 1927. While 
there are undoubtedly some cases in which improvement occurs, the 
vast majority will be found to progress rather than regress as term is 
approached. 

The effects upon the fetus are more severe. At least 50 per cent termi- 
nate in abortion, miscarriage, or premature birth. If the patient escapes 
these complications fetal death in utero during the last few weeks of the 
pregnancy is always to be considered. In addition, the deaths from pre- 
maturity, monstrosity, and diabetes in eai'ly infancy raise this mortality 
to 65 per cent or more. Here again the proper treatment with diet and 
insulin, especially if it be instituted early should result in a decided lower- 
ing of the fetal mortality; nevertheless, we must not lose sight of the 
fact that the combination of diabetes with pregnancy is a treacherous one 
for both mother and child because we meet with numerous eases in which 
the presence of the disease is unsuspected until fetal death occurs ; sec- 
ond, the glycosuria and the glyeemia are so variable day by day that it be- 
comes impossible to accurately judge the danger to the fetus ; third, there 
seems to be no relationship between the severity of the diabetes and fetal 
mortality; last, the use of general anesthesia is apt to precipitate an at- 
tack of coma. 

In view of all these possibilities it is becoming a recognized fact that 
when the child is an important factor in the case the unborn child’s best 
interests are served by the performance of abdominal cesarean section 
about thi'ee weeks before the expected date of delivery. The fact that 
these mothers are prone to have larger babies than usual is an added rea- 
son for this procedure. The avoidance of prolonged labor and the use of 
spinal anesthesia reduce the possibility of coma to a minimum. Last, if it 
be deemed advisable to prevent future pregnancies, sterilization can be 
done at the same time. Abortion as a routine in the diabetic is to be con- 
demned. The induction of premature labor, particularly in the primipara, 
because of the manipulation necessary, the length of time required, and 
the poor resistance of such a patient must be considered a dangerous pro- 
cedure for both mother and child and must give way to abdominal section. 

Since 1920 we have had 36 eases of pregnancy complicated by diabetes at 
the Jewish Hospital of Brooklyn, both ward and private. These women 
have had a total of 121 pregnancies resulting in 74 live babies a fetal mor- 
tality of 38.8 per cent. Were Ave able to exclude those live babies born be- 
fore the appearance of the diabetes the fetal mortality Avould unquestion- 
abW rise to 50 per cent or more. The results of the 36 pregnancies handled 
by us were as follows : 



RONSHEIM: DIABETES AND PREGNANCY 


713 



ONSET NUMBER THERAPEUTIC 
ABORTION 

MISCAR- 

RIAGE 

PREMATURE 

LIVE SB 

TERM 

LIVE 

TERM 

SB 

TOTAL 

LIVE 


Antegestational 27 7 1 3 4 9 3 12 

Intragostational 9 1 112041 


Excluding those cases that were subjected to therapeutic abortion we have 


Total number of eases 

28 


Total live births 

13 


Total stillbirths 

13 


Miscarriages 

2 


Antegestational onset 

20 

Live births 12 

Intragestational onset 

8 

Live births 1 

Maternal mortality 

1 



At the present time we have under consideration the carbohydrate me- 
tabolism in pregnancy. This work will require considerablj’- more time and 
when completed will form the basis of a report of tvhich this paper may be 
considered an introduction. From the infonnation already obtained and a 
study of these cases in conjunction with a review of the literature we be- 
lieve the following conclusions may be dratvn : 

1. Latent diabetes is a greater menace to the fetus than frank diabetes. 

2. With proper treatment and cobperation on the part of the patient 
fetal mortality should be considerably reduced. 

3. Uncontrolled diabetes \vill almost invariably result in (a) miscar- 
riage, (b) premature birth of a live child which may or may not survive, 
(c) death of the fetus in utero a few weeks before term. 

4. Since the dangers to the unborn child are so great, cesarean section 
about three weeks before term must be seriously considered, particularly in 
the primiparous woman or where no previous pregnancy resulted in a live 
birth. 

5. General anesthesia with ether or chloroform is to be avoided because 
of the danger of precipitating coma. The possibility of sloughing of the 
tissues from infiltration anesthesia must be borne in mind. 

6. Repeated blood sugar determinations must be a part of routine pre- 
natal care, since glycosuria may appear too late to prevent damage to the 
pregnancy. 

7. In cases of recurrent miscarriages or stillbirths without determinable 

cause, the sugar tolerance test may indicate that the patient is a potential 
diabetic. 

8 Determination of the sugar content of the amniotic fluid and of the 
tetal urine will help in establishing the diagnosis in some cases. 

205 Hicks Street. 


ABSTRACT OF DISCUSSION 

^^P®'^ONE.— My impression, from personal experience, of the present 






714 


AMERICAN JOURNAL OF OBSTETRICS AND GTNEC0L06T 


find out -what it is tliat kills these babies. I have several cases where I tried twice to 
carry out a pregnancy in an established diabetic before pregnancy; and each resulted in 
intrauterine death just before term. I am inclined to think there is some justification 
in offering cesarean section two weeks before term in the interest of the baby to these 
particular patients if they insist on further pregnancy. I have no fear of surgery in a 
diabetic patient provided I have the case under the care of a competent internist who 
controls the diabetes as he sees fit. 

DE. H. J. STANDEE. — I do not think one can make a definite statement about a 
patient with diabetes at the beginning of pregnancy. The effects of pregnancy or the 
effects perhaps of the fetal pancreas on diabetes are questions of great interest and I 
am quite convinced from six cases that I studied throughout pregnancy that there is a 
good effect on many of the diabetic patients as a result of the pregnancy itself. We 
have seen four patients who had a blood sugar around 150-200 ; the sugar tolerance test 
was way up, at the fourth hour it was still in the neighborhood of 200 mg. There was 
not any question about the diagnosis of diabetes. About the seventh month of preg- 
nancy the patients showed improvement, at the ninth month of pregnancy they had gone 
without using insulin, and approximately a month after their babies were born they re- 
verted to their prepregnancy state of diabetes. So I am convinced that in the milder 
forms of diabetes pregnancy, either through the fetal hormone or through the fact that 
the carbohydrate is used up mainly by the child, as is evidenced by the large child, 
exerts a good effect on the diabetes. I cannot agree mth the speaker and regard 
diabetes as always a very serious complication of pregnancy. Judging by the very 
severe cases of diabetes that I have had and those that we have studied, I believe if you 
get them early in pregnancy, the second month, and carry them through their pregnancy 
on a diabetic regimen in the hospital, having them come in for two or three days every 
second month and study them carefully, jmu can carry them througli. 

I cannot agree with the doctor on the desirability of cesarean section in diabetes be- 
cause I feel that while insulin has done a great deal, the diabetic patient is not quite the 
risk for cesarean section, and -ndth the results that we all know about in these children. 
I would not subject a patient mth diabetes to section, even at the seventh or eighth 
month, to get a live child. 


PRIMARY CARCINOMA OP BARTHOLIN'S GLAND* 

W. Benson Haber, M.D., P.A.C.S., Philadelphia, Pa. 

(From the Gynecological Department of St. Agnes Hospital) 

C arcinoma of Bartholin’s gland as a primary tumor is very rare. 

Rabinovitch, in the most recent contribution to the subject states that 
there are not over forty cases in the literature but unfortunately he does 
not append a complete bibliography. My own review of the literature re- 
veals only thirty eases of which several are doubtful. Probably the earli- 
est ease reported was that of Klob, who in 1864 described a tumor of 
Bartholin’s gland which had the appearance of a cystosareoma of the 
nipple. In 1880, Sinn while making an autopsj’’, found a tumor of un- 
doubted malignancj’’ originating in Bartholin ’s gland in a woman twenty- 
eight 3 "ears of age. August Martin, in his book cites a case of carcinoma 
of Bartholin ’s gland which recurred four years after removal of the orig- 
inal tumor. Geist in 1887 reported a case described as part tubular car- 


Read at a meeting of the Obstetrical Society’' of Philadelphia, November 3, 1932. 



harer: cakcikoma of Bartholin’s gland 


715 


cinoina and partscirrlius. Scliweizer and IMaclcenrodf both reported cases 
in 1893, but omitted such important details as the type of tumor, metas- 
tases, and final result. In fact, many of the reported cases arc quite in- 
complete so that we are unable to draw definite conclusions as to many 
interesting and important points. During the past forty years occasional 
conti’ibutions have been made to the subject, the most valuable of which 
are articles by 0. V. Frisch in 1904, Sitzenfrey in 190G, Spencer in 1913, 
and Palls in 1923. Only seven eases of primary carcinoma of Bartholin’s 
gland have been reported in American literature and of these, Lynch’s case 
is not fully described and Taussig’s case is somewhat doubtful. 

There has been much speculation as to the etiologj' of carcinoma of 
Bartholin ’s gland. Of course, nothing definite is known, but the some the- 
ories have been advanced as for carcinoma arising in other structures. 
Chronic inflammation is generally believed to be a predisposing factor in 
the development of carcinoma and has been jircsent in many of the re- 
ported cases. A definite history of neisserian infection was present in only 
one case. The role played by heredity is not well established. Onlj’’ two of 
the reported cases mention a history of cancer in the patient’s antecedents. 
There was no history of direct trauma in any reported case. As in other 
cancers, carcinoma of Bartholin’s gland is generally seen after the age of 
forty. In fact, more than half of the reported cases occurred in women of 
fifty or more years of age. The youngest was tAventy-eight and the oldest 
ninety-one. It has been found in unmarried women but not in virgins. Be- 
cause of the fragmentary character of many of the reports, the incidence of 
other possible etiologic factors cannot be determined. 

Two tj'pes of carcinoma arc possible in the previously noianal Bartho- 
lin ’s gland : ( 1 ) squamous cell tumors arising in the ducts near the surface 
of the gland and (2) columnar cell carcinoma or adenocarcinoma arising 
in the acini or in the epithelium of the deeper portions of the duets. Fur- 
thermore, it has been pointed out by Sitzenfrey, G. Noble and others that 
in cases of chronic gonorrheal infections of Bartholin’s gland a metaplasia 
of the normal columnar epithelial cells of the deeper portions of the ducts, 
occurs with their conversion into squamous cells so that the entire excre- 
tory duct may be lined Avith squamous cells. Hence in such a gland, a cai’- 
cinoma arising CA^en in the deeper portions of the ducts would be of the 
scirrhus type. It is also possible that a carcinoma arising from the colum- 
nar cells of the deeper portion of the gland may, as the tumor develops and 
approaches the surface, come to resemble a squamous eell carcinoma, a 
phenomenon comparable to that seen in certain adenocarcinoma of the 
cervix uteri. In fact, it seems quite likely that this is the explanation of 
* both Geist ’s and Spencer ’s cases. 

Because of the extreme rarity of the condition the correct diagnosis is 
rarely made although actually the diagnosis is easy Avhen the possibility of 
cancer is kept in mind. The presence of a hard lump in the posterior part 
of the labium majus, painless at first, later becoming painful and accom- 
panied by edema of the vulva and sldn over Bartholin’s gland and hard. 



716 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


shotty enlargement of the inguinal lymph glands in a woman beyond the 
age of forty, should make one suspect carcinoma of Bartholin ’s gland. The 
ehronicity of the disease, its failure to respond to ordinary therapeutic 
measures, the tendency to degenerative processes in the tumor, and biopsy 
in doubtful cases, establish the diagnosis. 



Fig. 1. — Low-power microscopic view of primary adenocarcinoma of Bartliolin’s gland 
showing duct. Magnified eighty diameters. 



Fig. 2. — High-powered microscopic picture of primary adenocarcinoma of Bartholin’s 
gland. Portion of duct is seen at upper right-hand corner. (280x.) 


Case Sistory. — Mrs. H. H., white, aged thirty-three, married, para 0, no miscarriages, 
admitted with a complaint of ‘ ‘ Swelling at entrance to vagina and profuse irritating 
vaginal discharge. ’ ’ 

About eight or nine months ago the patient first noticed a small, hard, painless lump 
in the posterior part of the left labium. It caused no discomfort so she paid no further 
attention to it until about April 1, 1932, when, during the course of a general physical 













HA1?ER; CARCINOMA OF BARTHOLIN’S GLAND 


717 


examination, slio called tlie internist’s attention to the mass. ' At that time she was told 
it was simply a small glandxilar cyst of no importance whatsoever but was advised to 
have it removed simply because it was growing larger. About this time .she noticed a 
very irritating vaginal discharge which became more and more profuse and could not be 
relieved by ordinary doxiches. Tliis continued until April 18, 1932, at which time she 
presented herself to me for treatment. 

Patient’s previous history uneventful .and there was no malignancy in the f.amily. 
^tenstruation normal. Last period March 25, 1932. No pregnancies. No operations. 

Physical Eoraminatioj }. — White adult female of good bony and muscular develop- 
ment, with a moderate enlargement of the thyroid gland, chiefly of the loft lobe. The 
he.art shows an cxtrnsystolic arrhythmia but is otherwise negative. Pelvic ex.amination 
reveals a hard lump about the size of a walnut in the left labium ma.ius in the position 
of Bartholin’s gland. It is freely mov.able and not tender. There is a slightly irregu- 
lar or lobulated outline to the mass on careful palpation. The skin over the tumor is 
freely mov.able, slight!}’ inflamed but otherwise normal. No enlargement of any of the 
regional !}anphatics could be detected. The skin of the inner surface of the thighs and 
of the l.abia is moderately inflamed. The vagin.al mucosa is inflamed .and bathed in a 
thin watery secretion. The cervix is inflamed but otherwise presents the normal ap- 
pearance of a nuUiparous cervix. The uterus and adnex.a are normal. 

Vaginal smears were negative for gonococci but showed B. coli and Trichomonas 
vaginalis in Large numbers. 

Blood count normal. 

A di.agnosis of tumor of Barthobn’s gland was made and operation advised. Be- 
cause it was nearly time for her menses, the patient would not submit to operation until 
May 2, 1932. At that time the tumor was excised under nitrous-oxide-oxygen anesthesia. 
It was enc.apsulated and shelled out with the greatest case. The incision avas closed 
with interrupted catgut sutures and healed by primary union. The patient was dis- 
charged from the hospital on the fourth d.ay and told to report to my offlcc for further, 
treatment of her Icucorrhea. The malignant character of the tumor was not discovered 
until sections were cut and studied. An attempt avas then made to communicate aadth 
the patient but it avas discovered that she had gone out of town on a vacation. Her hus- 
band avas accordingly acquainted avith the facts of the case, and upon return of the pa- 
tient, she aa’as again taken to St, Agnes’ Hospital avhere on .Tuly IS, 1932, she aa-as given 
1200 mg. hr. of radium over the affected area, and a careful se.arch again was made for 
possible evidence of lymphatic involvement. At that time the left labium avas perfectly 
healed and free of all induration. No evidence of meUistasis or recurrence avas found. 
Her vaginal discharge cleared up promptly with the use of tincture of green soap fol- 
lowed by the application of 5 per cent solution of mcrcurochrome and the liberal use of 
kaolin and soda bicarbonate. 

Pathologic Report , — Gross examination: The specimen is an irregular lobate tumor 
3 by 2 by 1.5 cm. avhich apparently has been well encapsulated and this capsule with 
underlying parenchyma lias been incised at one place. When sectioned the substance is 
firm, pale, and quite homogeneous in texture. Sections cut from both ends. 

Microscopic examination: Sections show the mass to consist, almost entirely, of epi- 
thelial cells massed together in an irregular fashion or sometimes arranged in incom- 
plete alveoli. Many of the nuclei of these cells are large and gr.anular. In an occasional 
nucleus are seen mitotic figures. Along the edge of one section there is seen a duct 
which closely resembles the ducts usually seen in Bartholin’s gland. 

Diagnosis . — Adenocarcinoma of Bartholin ’s gland. 

REFERENCES 

Kloh, J. M.; Pathologische Anatomic der w’eiblichen Sexualorgane Wien, W. 
Braumuller, 1864. Martin, A.; Diseases of Women. Klein: Strieker Handbuch 
der Lehre von den Geweben, Leipz. 72: 648, 1871. Langerhans; Virchows Arch, f. 
path. Anat. 61: 208, 1874. Geist: Inaugural Dissertation, Marburg, 1880, Thomas, 



718 


AMERICAN JOURNAL. OP OBSTETRICS AND GYNECOLOGY 


J.: Inaugural Dissertation, Marburg, 1880. Sinn, TV.: Inaugural Dissertation, Mar- 
burg, 1880. deSinety: Compt. rend. Soc. de biol. 7; 280, 1880. Mackenrodt: Ztscbr. 
f. Gynak. 26: ISO, 1893. Schweiser; Arch. f. Gyniik. 44: 322, 1893. Honan, J. H.: 
Inaugural Dissertation, Berlin, 1897. Godart: Bull. Soc. Beige de Gynec. 9: 109, 1899. 
Trotta; Arch, di Ost. e Ginec. 193, 1900. Schaffer, S.; Ztschr. f. Gebnrtsh. u. Gyniik. 
1; 193, 1903. Hurghele, TV. N.: Ztschr. f. Geburtsh. u. Gynak. 1 : 1102, 1903. Frisch, 
0. F. : Monatschr. f . Geburtsh. u. Gyniik. 19 : 60, 1904. Sitzenfrey, A. : Zentralbl. f . 
Geburtsh. u. Gynak. 58: 363, 1906. Janibon and Chahonx; Lyon Med. 112: 3, 1906. 
Kelly, H.: Operative Gynecology, 257, 1907. Tape; Deutsche med. 'Wchnschx. 33: 
1620, 1907. Spencer, H.: Proc. Eoyal Soc. 7 : 109,1913-14. Fden: Proc. Eoyal Soc. 
7: 102, 1913-14. Taussig, F. J.; Am. J. Obst. 76: 794, 1917. Gomes, L. A.: Thesis, 
Montpellier, 1914. Lynch, F. TF. : Pelvic Neoplasms, 32, 1922. Falls, F. H.; Am, J. 
Obst. & Gyneo. 6: 673-680, 1923. Neuioirth, K.: Monatschr. f. Geburtsh. u. Gynak. 
70: 93-99, 1925. Hunt, F. C., and Powell, L. H.: S. Clin. N. Am. 6: 1325-1328, 1926. 
Schneider, P.: Zentralbl. f. Gj’niik. 32: 1986, 1930. Pahinovitch, J.: Am. J. Obst. & 
Gyneo. 23 : 268-274, 1932. 


ABSTBACT OF DISCUSSION 

DR. JOHN A. McGLINN. — I have never seen a case nor can I recall a similar case 
having been presented. •> 

There is no gland, with the possible exception of the salivary, which works more in- 
tensively and more frequently to fulfill its physiologic function in the body, and none as 
subject to great and more frequent traumatism, or to more widespread infection. And 
yet in spite of all this, carcinoma occurs but rarely, so rarely that in all the literature of 
the world only forty eases appear. 


DODERLEIN’S BACILLUS IN THE TREATMENT OF VAGINITIS*^ 

Roy W. Mohler, M.D., F.A.C.S., and Claude P. Brown, M.D., 

Philadelphia, Pa. 

(From the Gynecological Department of Jefferson Medical College) 

W E ARE presenting a preliminary report on the treatment of vaginitis 
with pure viable cultures of Doderlein’s bacillus. So far as we Imow 
this form of treatment has not been reported in American literature. A 
statement of the favorable results secured and an explanation of the 
physiologic principles upon which the treatment is based are the purposes 
of this report. 

In contemplating any treatment for vaginitis which may be the cause 
of leucorrhea we must first exclude the possibility of a latent infection of 
the cei’vix and Skene’s tubules. The cervix is excluded as the source of 
the vaginitis when- there is no eversion or erosion present and when its 
secretion is moderate in amount and contains none or only a few pus cells. 
The Skene’s tubules are regarded as normal when there is no granulation 
about them and when no pus cells and onlj'- a few epithelial cells can be re- 
covered from them. 

Pa^st Treatment . — In most of the published reports in the English 
language with which we are familiar, mechanical cleansing of the vagina 
and the application of antiseptics have been the basis of treatment for 
vaginitis, particularly the so-called Trichomonas vaginalis vaginitis. 


Read at a meeting of the Philadelphia Obstetrical Society, November 3, 1932. 



aroni.ER AND BROWN: DODEREEIN 'S BACILLUS 719 

lileeliauical cleansing is a very important factor, but it is inadvisable to so 
tliorouglib^ cleanse the vagina that tbc natural resistance of the mucosa 
is impaired by the trauma produced bj’- scrubbing. Antiseptics may be 
used wbicli will kill the parasites and most of tlie bacteria present in the 
vaginal canal, but tliey maj’- also impair the normal activity of tbe mucosa 
to a point where its autogenous property of overcoming infection is lost. 

Normal Vaginal Secretion . — There is undoubtedly a physiologic mech- 
anism which maintains a balanced secretion in the vaginal canal from 
infancy to old age. There are occasional glands present in the mucosa of 
the vaginal canal. The mucus from the cervix and the glycogen contain- 
ing epithelium of the vagina are the normal sources of the vaginal 
secretion. 

Abrahams' from his observations maintains that the healthy infant has 
an acid vaginal secretion and that in children with chronic diseases this 
changes, becoming alkaline. According to the Schroder school, the vag- 
inal bacillary flora prevails after one year of age. These authors regard 
the bacillai’y flora of the vagina as normal in healthy children. In the 
normal woman past puberty, the normal vaginal secretion consists of 
epithelial cells and vaginal bacilli of Doderlein with a high concentration 
of lactic acid which is considered important for the self cleansing of the 
vagina. A number of writers are of the opinion that the lactic acid is 
formed from glycogen under the influence of these bacilli found in the 
vagina. According to some authors the degree of acidity of the secretion 
and its variations are dependent on the glycogen found in the vaginal 
walls and is influenced by the general condition of the vaginal membrane. 
Schroder, Puploslvj^ Demme and others assume that the glycogen is trans- 
formed into a monosaccharide as the result of fermentation and that the 
monosaccharide serves as the material for the formation of the lactic acid 
when acted upon by some bacilli of the vagina. This assumption is based 
on the fact that the vaginal bacilli grow poorly in a glycogen containing 
culture and in such cultures no acid formation takes place. If this be true 
it would seem that all women should be free of symptoms during the child- 
bearing age regardless of parity when there is no hypersecretion from the 
cervix and when the vaginal secretion is acid in reaction and consists of 
epithelial cells and Doderlein ’s bacilli. 

The physical characteristic of the vaginal canal seems much altered 
after the artificial or natural menopause. This is, of course, very difficult 
to determine definitely, since one must draw conclusions from patients 
who have sjnnptoms. The impression that is formed after examining 
many patients who have passed the menopause is that atrophy has oc- 
curred, the cervix is small, the mucosa is thinner and not as succulent as 
in the childbearing woman. The vaginal secretion is reduced in amount, 
thinner in consistency, white in color and not flalry as found in the pre- 
menopausal woman ; it contains epithelial cells, many pus cells and many 
organisms of various types, both cocci and bacilli ; the hydrogen ion con- 



720 


AMERICAN JOURNAL OE OBSTETRICS AND GYNECOLOGY 


centration seems to have changed becoming less acid in reaction ; the 
vaginal bacilli of Doderlein are absent. Although the vaginal secretion 
seems to change after the menopause many of these patients do not com- 
plain of leucorrhea. It would seem that the atrophy of the vaginal 
mucosa and the reduction of its glycogenic function together with a lessen- 
ed secretion from the cervix would explain the absence of discharge suf- 
ficient to cause a leucorrhea. 

FLORA OP LEUCORRHEA 

After these remarks and hypotheses regarding the normal vaginal secre- 
tion it seems desirable to discuss the question of the bacterial flora of the 
pathologic vaginal discharge. Curtis® made a very extensive study of the 
etiologj^ and bacteriology^ of leucorrhea. He concluded that ‘ ‘ fresh prepa- 
rations from the uneontaminated vaginal canal show almost exclusively 
Doderlein ’s large gram-positive vaginal bacilli. Most clinically normal 
women show bacilli of this type. The more patients deviate from the 
normal with regard to Doderlein ’s bacilli, the greater the tendency to dis- 
charge formation and the more purulent its nature. The characteristic of 
smears and cultures from leueorrheal discharges is the preponderance of 
anaerobic organisms. ’ ’ Since Curtis published his work, the Trichomonas 
vaginalis has been cited as one of the chief causes of vaginitis. Within the 
last few years much literature has appeared on this subject and many treat- 
ments have been advised. 

Without entering a controversy upon this matter it would seem that, al- 
though one can see the Trichomonas vaginalis frequently’’ when vaginitis 
is present, there are also other factors which are fairly' constant and cannot 
be ignored ; the organisms referred to by Curtis, the constant changes in 
the vaginal wall and introitus of the vagina, characterized by mottling and 
redness, especially^, marked in the fornices and the vestibule of the vagina 
and the frequent appearance of droplets of serum transudate on the mu- 
cosa of the vagina and portio. We must then consider whether the changes 
in the vaginal wall are secondary’’ to infection with the Trichomonas 
vaginalis or other organisms, or Avhether the changes in the vaginal canal 
are primary’ and the contamination with these organisms secondary. If the 
changes in the vaginal canal are primary’, the endocrine sy’stem may’ be a 
factor in the production of vaginitis. This is substantiated theoretically’ 
by two observations ; namely’, the change in the vaginal secretion after the 
menopause and the improvement of some of these patients after the use 
of glandular therapy’, viz., thyroid extract. The determination of the im- 
portance of the endocrine factor in vaginitis is not the purpose of this re- 
port ; to prove this would involve very’ extensive studies, which so far as 
we know have not been completed ; that is, the study’ of the vaginal secre- 
tion and flora throughout the menstrual cy’cle, first of the normal woman 
and second of the diseased patient. These studies should be made on a 
large series of cases at not more than five day intervals throughout a num- 
ber of menstrual cycles. 



MOHLER AND BROWN: DODERLEIN’S BACHXUS 


721 


BIOLOGIC TREATMENT 

The treatment of vaginitis by means of some biologic principle has been 
tried a number of times. Llewellyn and Block^ in 1917 gave a report 
based on the use of Bacillus bulgaricus which was rather satisfactory when 
one considers that at that time eversion of the cervix and endoeervicitis 
were not being treated so frequently with the cautery as at present. Yeast 
fungi of the saccharomyees cerevisiae or brewing type has been used by 
some for a considerable period of time Avith a fair degree of success. 
Loeser, Andreitschuk, Smorodintzeva and Tumanoff, and other foreign 
investigators have given reports on the treatment of vaginitis bj’- planting 
pure cultures of the vaginal bacillus in the vagina. Our first attempt to 
develop a treatment for vaginitis by some biologic means Avas to use sugar 
of milk in the vagina after a cleansing douche of plain Avater, the idea be- 
ing to supply a medium for the dcA^elopment of lactic acid from the flora 
present. The next thought Avas to use together Avith the sugar of milk 
some type of acidurie organism AAdiich Avould develop lactic acid in the 
A'agina. Thomas* reported that the Bacillus acidophilus and Doderlein 
bacillus were indcntieal, and since the Bacillus acidophilus Avas easilj^ avail- 
able, it was used Avith the sugar of milk. After some time the Bacillus 
acidophilus and sugar of milk treatment Avas replaced by the present 
treatment. 

METHOD OP TREATMENT 

About nine months ago one of us (M) made a culture from a virginal 
A^agina that appeared normal. Bacteriologic studies convinced one of us 
(B ) that the organism isolated AA'as the one described by Doderlein and this 
is the one used in the AA'ork hercAvith reported. This culture has been 
studied together Avith Bacillus acidophilus and Avhile culturally similar is 
serologically different. The Doderlein culture used is groAvn in a Avhey 
medium and after suitable groAvth it is prepared by mixing one-half 
ounce Avith enough sugar of milk to make a thin paste. The mixture is 
planted in the Amgina after cleansing with dry cotton and a small cotton 
tampon is then placed in the vaginal introitus. The treatment is carried 
out once every tAventy-four hours either by the physician or patient. If 
the patient carries out the treatment she does it preferably before retir- 
ing. After a cleansing douche of plain Avater the mixture of one-half 
ounce of the culture and sugar of milk is injected into the vagina with a 
soft rubber ear syringe the patient assuming a reclining position Avith the 
hips slightly elevated. A small tampon of cotton is placed in the vaginal 
introitus, and removed the folloAving morning. The patient repori^s at 
weekly intervals for clieck-up and study. Routine smears of the vaginal 
canal are made on each visit, when the secretion appears normal and when 
large numbers of Doderlein ’s bacilli are seen in the smears after staining, 
cultures are then taken to determine if the planted organisms can be 
recovered. 

All of the patients treated complained of a leucorrheal discharge 



722 


AjWERICAN journal of obstetrics and gynecology 


wliicli had failed to respond to other methods of treatment, such as cauter- 
ization of the cervix and Skene’s tubules and the application of antiseptics 
folio-wing thorough cleansing of the vagina. The vaginal secretions were 
studied by making the ordinary hanging drop unstained smear, and the 
Trichomonas vaginalis was frequently present. The stained smears con- 
tained many pus cells, epithelial cells and many tjqres of organisms which 
we did not try to classify. The vestibule of the vagina was hjqreremic and 
the vaginal wall showed various degrees of reddening and mottling which 
was especially marked about the forniees and portio. The Doderlein 
bacillus was constantly absent. 

RESULTS OF TREATMENT 

Twent3’'-one patients were treated. Six of these failed to carrj^ out 
treatment as recommended, but were improved so far as the symptom of 
leueorrhea was concerned while following the treatment. Nine patients 
are still rrnder observatioir, the hyperemia and mottling of the vaginal 
canal having disappeared, the vestibule of the vagina looks normally pink 
except in a few where there is a small area of hj’-peremia about the orifices 
of Skene’s tubules. The number of pus cells in the secretion from these 
areas is interpreted as implying that there is present a focus of infection 
which has not been destroyed. In some the mottling has persisted about 
a discrete area on tlie portio. Tliese nine patients have remained sj’^mp- 
tom free with irregular treatment but thej’- have not as j’-et responded to 
our criteria of cure. Six patients have remained symptom free, and we 
have recovered from their vaginal secretion cultures of the organisms 
planted. 

Proof of cure was based on absence of symptoms, the inability to find 
pus cells in large numbers in stained smears, failure of the vaginitis to re- 
turn after treatment has been discontinued and finallj’’ recovery of cultures 
of the implanted organisms from the vagina of the patient treated is our 
proof of cure. 

In presenting this report we are conscious of the fact that the treatment 
is more or less in the experimental stage and has not been given a long 
trial, it is preliminaiy to one on a larger series of cases. 

REFERENCES 

(1) Lleiuellyn and Block; J. A. M. A. 80: 2025, 1917. (2) Abraham, G.; Arch, 

f. Kinderh. 86: 211-226, 1929. Abraham, G.: Arch. f. Kinderh. 88: 305-306, 1929. 
(3) Curtis, A. S.: J. A. M. A. 84: 1706, 1920. Curtis, A. S.: Surg. Gyneo. Ohst. 
299, 1914. (4) Thomas, S.: J. Infect. Dis. 14: 218-227, 1928. (5) Smorodintzeva, 

A. A., and T^imanoff, G. N. : Vrach dielo. 12 : 721-723, 1929. (6) Andreitschuk, T. S.: 
Monatschr. f. Gehurtsh. u. Gynak. 86: 48-53, 1930. 

323 South Twentieth Street. 

ABSTRACT OF DISCUSSION 

DR. CLAUDE BROWN: Our interest in the Doderlein bacillus was aroused by Dr. 
Mohler’s observation that the vaginal tract, under normal healthy conditions, con- 
tained large number of Doderlein baciUus and particularly, if not entirely absent in 
those with vaginitis. 



MANN ET Ab. : ASCHHEIM-ZONDEK TEST 


723 


Two cultures have been under rather intensive studj’; these were both obtained by 
Dr. Mohler. The carbohydrate reactions were of no help. We, therefore, immunized 
some rabbits against these and B. acidophilus cultures, and then made agglutinations 
and adsorption studies rvitli the sera of these rabbits. This work leads us to believe 
that Doderlein bacillus .and B. acidophilus belong in the aciduric group, but are sep- 
arate entities. We feel fairlj- certain that Doderlein 's bacillus is not the acidophilus 
used in milk preparations and cultures used by the gastroenterologists, although 
Thomas in his studies reported them as identical. 

Because of the difficulties encountered in classification, Doderlein bacillus has not 
yet appeared in Gergey’s Manual of Determinative Bacteriology. However, studies 
are in progress which wo hope will cle.ar up the discrepancies. 


ASCHHEIM-ZONDEK PREGNANCY TEST, FRIEDIMAN 
MODIFICATION'' 

"With Report op 174 Cases 

Bernard Mann, M.D., F.A.C.S., David Meranze, M.D., and 
Leib Golub, M.D., Philadelphia, Pa. 

(From the Gynecological Department of Mt. Sinai Hospital) 

A TEST based on biologic findings and procedure is subject in its very 
nature to many limitations, both qualitatively and quantitatively. 
Such limitations are inherent both in the test material and in the experi- 
mental animal. Ho-wever, there are often fundamental mechanisms which 
can be relied upon in a great percentage of cases, provided certain condi- 
tions are stabilized. If, moreover, biochemical accompaniments of such 
mechanisms can be found, a successful procedure may be developed. The 
many functional tests in general use, often fall down in special instances 
because compensatory mechanisms, margins of safety and individual vari- 
ations come into play: for instance, in the performance of the glucose 
tolerance test or in the phenolsulphonphthalein test. In the test we are 
about to discuss such considerations hold to a lesser degree. 

Many procedures have been proposed for the detection of early 
pregnancy. Besides the Asehheim-Zondek tesP^ and its modifications the 
most important proposals have been those of Brocha,- Bercovitz,® and 
Manoilov.'* These latter procedures have been studied comparatively by 
"White and Severance® in a fairly large series of cases, and have been shown 
to be decidedly inferior in dependency to that proposed by Aschheim and 
Zondek. 

The test as proposed by Aschheim and Zondek has certain practical dis- 
advantages. It is admittedly difficult to have on hand, except in the more 
completely equipped laboratories, the large number of immature white 
mice required for the test, since for each test four to six such animals are 
necessary. Furthermore, if the mice are not used before the twenty-fourth 
day of their existence they mature and are of no further value for this 


♦Bead at a meeting of the Obstetrical Society of Philadelphia, November 3, 1932. 



724 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGT 


purpose. The technic, moreover, is quite tedious. The long time interval 
of one hundred hours is also a considerable disadvantage if the test is being 
used to determine the possible existence of an ectopic pregnancy. 

A decided practical advance was achieved when Friedman" proposed 
the use of the rabbit as a test animal and later demonstrated along with 
other workers® the dependability of this procedure. It had long been 
Imown that in the doe, the eat, and the ferret ova continually ripen, but 
ovulation does not occur without copulation, or its mechanical equivalent, 
such as stroking the vagina and the jumping of females. The ripe graafian 
follicles exist as large vesicles in the nonovulatory rabbit and are readily 
recognizable. "With ovulation they rupture ; the follicle is converted into a 
corpus hemorrhagicum and this in turn to a corpus luteum. Ovulation, 
therefore, is not cyclic but conditioned. Friedman in a series of pre- 
liminarj'- ph 3 ’-siologic experiments demonstrated that omlation could be 
induced without coitus in a number of ways. One such way was the 
intravenous injection of urine from pregnant women. He, therefore, sug- 
gested that this phenomenon could be used as a test for earty pregnancjL 
The suggestion was immediatelj’- taken up by various workers, and very 
favorable results reported.® 

It is such a series of cases that we wish to report. The Friedman modi- 
fication has all the advantages of the oinginal Aschheim-Zondek test and a 
number of practical superiorities, which will become evident as we discuss 
the test in detail. The test animal is a nonpregnant doe, over three months 
old or weighing more than four pounds. The doe should be kept in isola- 
tion for a period of four weeks prior to use. No large supplj’' of animals 
need, therefore, be kept on hand. The urine used is usually a fresh morn- 
ing specimen kept on ice over the period of its administration. The speci- 
men should also be warmed to approximately bodj’- temperature before in- 
jection. If turbid, it is probabty advisable to filter and to render slightly 
acid. "We inject about 30 c.c. of urine over a period of two days, usually 
in 5 c.c. portions as recommended bj’’ Friedman. This procedure can be 
varied within limits. Our technic differs from others in some respects. 
Manj’' inject much smaller quantities and laparotoinize and examine after 
twenty-four hours. In negative cases, these workers reexamine the animal 
after forty-eight hours. Our usual routine is to examine after forty-eight 
hours from the time of the first injection. We have deviated from this in 
this series only under verj'^ special circumstances and have found that the 
procedure has met the requirements of problems presented by hospital and 
private cases. This time interval, forty-eight hours, it will be noted con- 
stitutes a distinct time advantage over the original Aschheim-Zondek test. 
Larger quantities than 5 c.c. maj’' be administered in one injection and in 
special cases the animal can be examined after one day, always with the 
stipulation that if the test prove negative at that time the animal should 
be reopened twenty-four hours later. 

The appearance of the ovaries is quite characteristic. The detailed ap- 



:^IANN ET AL. : ASCHHEIM-ZONDEK TEST 


725 


pearance of the ovaries in negative and positive eases has been described 
in many papers. "We would like, however, to list a few observations which 
we consider interesting and important. Wliile the freshly formed corpora 
lutea are almost always characteristic in appearance, yet occasionally an 
old corpus Inteum may simulate it closely. Positive ovaries show the large 
corpora hemorrhagica which are almost black in color with or without rup- 
tured follicles. An old corpus hemorrhagicum in contrast is usually 
smaller and has a reddish rather than a blackish tint. In doubtful in- 
stances the ovaries can be sectioned and the suspicious area studied histo- 
logically. We have resorted to this procedure with satisfaction in a 
number of instances. The site of the hemorrhagic area should also be 
studied with care since in one instance in our series a hemoiThagic cyst of 
the same size and appearance as that seen in positive ovaries was found 
outside of the ovary, in the meso-ovarium. The ovaries in this particular 
case were entirelj^ negative, macroseopically and microscopically. We, 
too, have obtained some aid from the gross appearance of the horns and 
uterus on opening the abdomen. These are in the positive cases usually 
darker in color and edematous. 

Very frequently the enlargement of the mammary glands may suggest 
the outcome of the test even before laparotomy. This enlargement cor- 
responds microscopically with a hyper'plasia of the glandular elements of 
the mammary glands. We would like to caution the workers with rabbits 
not to place absolute reliance on the testimony of their dealers, as oe- 
casionallj’’, male rabbits are sent in and in this way valuable time and 
sometimes irreplaceable material ar'e lost. Examination of the rabbit im- 
mediately before use as to its sex will prevent this mistake. It may be ad- 
visable in the event that the injeeted urine produces death in the animal 
by virtue of some toxic property to detoxify the urine by extraction with 
ether as recommended by some authors. It has been our experience that 
operating in the Trendelenberg position immediately after etherization 
greatly facilitates and shortens the operation. 

In the operation itself no asepsis need be observed. The resistance of 
the animal to infeetion is remarkable. Even under the most adverse op- 
erative conditions the animal morbidity and mortality are low. On re- 
opening rabbits a second or even a third time we find invariably that no 
active infection is present. However, we verj’^ frequently find in these 
reoperated rabbits adhesions and cysts, chiefly within the abdominal wall, 
cysts filled with sebaceous-like material. On sectioning these cysts, we 
find them lined in part by stratified epithelium and filled with necrotic 
infected matter, very effectively circumscribed. In addition the animals 
seem to suffer slight ill effects from traumatic injuries to bladder or in- 
testine, if these are punctured and repaired. We feel, however, that an 
animal should not be used more than twice, particularly in view of the one 
false negative to be described. 

It is now our purpose to analyze the results of 174 consecutive tests in 



726 AIMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 

which we employed the Friedman modification of the Asehheim-Zondek 
test. Nearly all of these were problem cases in which help was sought 
from the test used and in which subsequent procedure was guided by the 
results so obtained. All of our cases were followed up clinically. In this 
series we obtained 91 positive tests on 79 eases. Pregnancy was definitely 
established in 77 of these cases. There were two positive results in con- 
ditions other than pregnancy. We describe these further on in detail. 
There ivere two incorrect positives, giving a percentage of accuracy of 
97.8 per cent. The results of this group are given in Table I. We con- 
sidered pregnancy as established two weeks following the last menstrual 
period. 


Table I. Analysis op Positive Tests 


NO. OF POSITIVE 

TESTS 

NO. OF TESTS 

IN PRO\^ 
PREGNANCIES 

NO. OF CORRECT POSITIVE 

TESTS IN CONDITIONS 
OTHER THAN PREGNANCY 

INCORRECT 

POSITIVES 

PER CENT OF 

ACCURACY 

91 (79 cases) 

89 (77 cases) 

2 

2 

97.S 


Table II represents the number of cases diagnosed at the various stages 
of pregnancy noted. These were : 



Table II. 

Stages 

OF Pregnancy Giving Positive 

Pesults 


UNDER ONE 

MONTH 

SECOND 

MONTH 

THIRD 

MONTH 

fourth 

MONTH 

FIFTH 

MONTH 

SIXTH 

MONTH 

SEVENTH 

MONTH 

EIGHTH 

MONTH 

17 

29 

13 

9 

5 

2 

1 

1 


Citation of the following positive cases is of interest. 

Case 1. — One patient having regular menstrual history up to September 5, 1931, 
developed irregular bleeding, elevated temperature, and pain in the lower abdomen. A 
pregnancy test done November 7, 1931, was positive. An unruptured ectopic preg- 
nancy was suspected. A laparotomy was performed and the diagnosis of unruptured 
ectopic pregnancy confirmed. 

Case 2. — One patient had amenorrhea of two months ’ duration. A pelvic examina- 
tion showed the uterus to be enlarged to the size of a two months ' pregnancy, and in 
addition bilateral cysts of the ovary. A pregnancy test done at this time was positive. 
A laparotomy was performed. The cysts proved to be dermoid in character. One 
ovary also contained a corpus luteum of pregnancy. 

Case 3. — This is a case of a woman of approximately three and one-half months’ 
pregnancy on whom a test was positive. The patient had an ovarian cyst which sud- 
denly became twisted on its pedicle. A laparotomy became imperative and was per- 
formed on the same day. The diagnosis of a twisted ovarian cyst was substantiated. 
The patient was discharged in good condition. Signs of a viable fetus which had been 
present suddenly disappeared in the sixth month of pregnancy. Bleeding ensued. A 
test performed at this time was negative. A dilatation was done and a dead fetus 
and other products of conception were obtained. 

The two positive results in conditions other than pregnancy are the 
following ; 




]\IANN ET AL. : ASCUHEIM-ZONDEK TEST 


727 


Case 4.— One patient, twenty-two years of age, presented herself with a normal 
menstrual history followed by periods of amenorrliea and vaginal bleeding. A curet- 
tage was performed and a pathologic diagnosis of hydatidiform mole was made. The 
subsequent tests were negative. 

Case 5.— Mrs. S., aged thirty-two, was admitted to the hospital with a diagnosis of 
hydatidiform mole. Pregnancy test at this time was positive. This diagnosis was 
substantiated by a curettage. The test continued positive for three months following 
which period they have remained negative for the ensuing eleven months. 

Two false positives were obtained in our scries. The first instance of an incor- 
rect positive was that of a patient tAventj'-eight years old, para iv, who missed one 
period. A urine specimen collected at this time gave a positive result. A few days 
later the patient had a menstrual flow. 

The history of the second case reported to us, was acute lower abdominal pain and 
amenorrhea of three months ’ duration. The test for pregnancy was positive. Ectopic 
pregnancy was suspected. A laparotomy was performed. No ectopic was found. One 
month later the patient passed a “piece” of tissue which unfortunately was not sub- 
mitted for an examination. Following this the patient was admitted to the hospital, 
and a curettage was performed because of continued bleeding. The pathologic diag- 
nosis on the tissue so obtained was hyperplasia of the endometrium. The pregnancy 
test at this time was negative. Though there is a possibility that the ‘ ‘ piece ’ ’ of tis- 
sue expelled contained products of conception we are listing it as a false positive. 

Eiglity-tliree tests (71 cases) were negative. Of these in 70 cases preg- 
nancy was definitely excluded by our follow-up. One test was incorrect, 
giving a percentage of accuraej' of 98.8. 


Table III 


NO. OF negative TESTS 

NO. OF TESTS PROVED 
NEGATIVE CLINICALLY 

NO. OF INCORBECT 
NEGATIVE TESTS 

PER CENT OP 
ACCURACY 

83 (71 cases) 

82 (70 cases) 

1 

98.8 


The following were the final diagnoses in these 70 eases: 4 eases of 
uterine fibroma, 5 cases of lactation amenorrhea, 1 case of tuboovarian ab- 
scess, 5 cases of dead fetus, 29 cases of missed one period (had period next 
month), 8 eases of irregular menstrual bleeding, 1 case of very scant men- 
struation at the time of last period (married seven months), 3 cases of dis- 
placed uterus, 1 ease of nausea and vomiting (gastritis due to asearis lum- 
hrieoides), 1 case of tenderness in the left lower abdomen (suspected 
ectopic), 2 eases of pseudoeyeses, 1 ease of sclerotic ovary and adhesions, 

1 case of the last period lasting only three days instead of usual seven 
days, 4 eases of amenorrhea and menopause, 1 case of chronic salpingitis, 

2 cases of endocrine dysfunction, and 1 case of incomplete abortion (bleed- 
ing for ten days). 

The single instance of a false negative occurred during a demonstration 
of the accuracy of the test. Two separate portions of a known positive 
urine were injected into two rabbits. One of these rabbits had never be- 
fore been used for this purpose. The other rabbit had been so used on two 
previous occasions. In the former rabbit the result was positive. The 







728- 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGT 


latter rabbit was negative. In its abdominal wall were found many cysts 
containing a sebaceous material and also many adhesions between the in- 
testinal coils and between the intestinal coils and abdominal wall. 

In summarizing the results we performed 174 tests, of which 171 gave 
correct results, giving a percentage of accuracy of 98.2. 


Table IV 


NO. OP TESTS 

NO. OP CORRECT RESULTS 

PER CENT OP accuracy 

174 

171 

98.2 


In conclusion we may state: 

The results of this series of 174 tests have demonstrated the value of the 
Friedman modification of the Asehlieim-Zondek test in the diagnosis of 
early pregnancy. 

It has further proved of invaluable assistance in the differential diag- 
noses of suspected pregnaucj'", lij’^datidiform mole, and chorionepithelioma 
from a large variety of conditions simulating them. 

The test has in two instances enabled us to follow the course of hj^datidi- 
form moles in a manner previously impossible. 

The Friedman test is practical, easily performed, and readily adaptable 
in the ordinarily equipped laboratory, and permits of an unusually high 
percentage of accurate diagnoses. 

245 South Sixteenth Street. 

ABSTRACT OF DISCUSSION 

DR. CHARLES MAZER.— This report, coming from a man who utilized the test 
from the clinical and not laboratory standpoint, is of great importance in evaluating 
the Friedman pregnancy test in problem cases. When the test is employed on normal, 
nonpregnant women, the results are misleading, for in them we rarely encounter a 
false, positive reaction. 

There is no doubt that the Friedman modification of the Aschheim-Zondek pregnancy 
test is superior to the original test. It practicallj" requires no technical experience. 
The country physician without laboratory facilities can perform the test with ac- 
curacy. If he encounters difficulty in entering the marginal ear -vein, the subcutaneous 
injection of a larger quantity of urine will render equally good results. Because of the 
simplicity of the procedure and the availability of the test animals, the results are more 
accurate. 

The Friedman test, like all other biologic tests, is, however, not free from an element 
of error when employed in problem cases. The false, positive reactions are most embai - 
rassing, leading to unnecessary operations in the diagnosis of unruptured ectopic gesta- 
tion and other conditions. 

There is always a remote possibility of an excess production of anterior pituitaij 
sex hormone in the nonpregnant w'oman suffering from a primary ovarian failure, 
hyperthyroidism or a large ovarian cyst, mistaken for a pregnant uterus. I am, there- 
fore, employing the Friedman and estrin tests simultaneously. When the two tests 
agree, we are fairly sure of an accurate diagnosis. If, however, they disagree, the 
negative test is repeated. 




C0SGR0^^3 AND WATERS: ELLIOTT TREATMENT 


729 


The question is often asked Avhy the urine should be acidified, if alkaline, before the 
injections are given. It must be remembered that the gonad-stimulating hormone is 
unstable in an alkaline medium and the acetic acid is added to the alkaline urine in 
order to preserve the stability of the hormone. 

DE. MANN (concluding). — Up to our ninetieth case our results were correct 100 per 
cent. I suppose, that as our number of tests increase, our percentage of correct re- 
sults may not be as good as thcj' were in this series. 


INJURIES TO THE VAGINA RESULTING PROM THE 
ELLIOTT TREATMENT'' 

Samuel A. Cosgrove, M.D., P.A.C.S., and 
Edward G. Waters, M.D., P.A.C.S., Jersey City, N. J. 

T he “Elliott Treatment” is a means of applying lieat to the pelvic tis- 
sues by means of a mechanical device whereby water at temperatures 
up to 130° F. is circulated under pressure through a collapsible bag in- 
troduced into the vagina or rectum. The procedure has been enthusiasti- 
cally recommended for a variety of acute and chronic pelvic inflammatory 
states. It may well be considered a priori that prolonged and/ or frequently 
repeated exposure of tissues to such a degree of heat may be productive of 
local damage to these tissues. 

The following eases are presented without discussion either of the pro- 
priety of the indications for treatment, or the competence of the technic in- 
volved, to show that such damage with reference to the vagina does actually 
occur. 

Case 1. — '(E. G. W.) T. D., tbirty-fouv years, meniugitis and dipbtberia in early 
cliildbood, with complete recovery. Pleurisy (tuberculosis ?) nine years ago. Ap- 
pendicectomy and tubal resection eight years ago. Married fourteen years, three living 
children. 

No miscarriages. Menses, regular type, but last only two days. Eor the past 6 or 8 
years, has had a persistent vaginal discharge, and for past six years has been treated at 
intervals for “ulcers of the womb.” Also, has persistently used medicated douches. 
A few years ago was curetted for the same trouble. Accompanying the discharge there 
has been a constant pain felt low down on the left side, aggravated by constipation and 
especially by intercourse. There are no urinary or digestive symptoms. The appetite is 
fair and the patient sleeps well. In the past year the patient has lost 18 pounds, the 
present weight being 120% pounds. Fairly well developed and nourished. Presented 
tenderness in the left lower quadrant. Parous but fairly tight introitus. Cervix site of 
numerous nabothian cysts. Uterus slightly enlarged. Small sessile fibroid on the ante- 
rior surface of the uterus. Both adnexa slightly enlarged and very tender. 

The cysts were destroyed with the cautery. A series of Elliott treatments was begun, 
as follows : 

1/13/32 — 35 minutes, 2 pounds’ pressure, 128° to 130° 

1/20/32 — 40 minutes, 2 pounds’ pressure, 128° to 130° 

1/25/32 — 40 minutes, 2 pounds’ pressure, 128° to 130° 

1/29/32 — 40 minutes, 2 pounds’ pressure, 128° to 130° 


‘Read at a meeting of the New York Obstetrical Society, October 11, 1932. 



730 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


Inspection of the vagina at the time of the next visit, February 3, showed marked 
burns of tlie cervix and upper vagina, the whole of the upper three-quarters of the 
vaginal tract presenting a moist, grayish, diphtheritic appearance, with interspaced 
areas of angry looking, beefy red tissue. The discharge was very odorous. The amaz- 
ing part of the whole picture was the lack of marked discomfort on the patient’s part, 
her only complaint being urinary frequency and some dysuria. There were moderate 
numbers of red blood cells and some pus cells in the catheterized specmien, Elliott 
treatments were continued, as indicated below : 


2/ 3/32 — 35 minutes at 2 pounds’ pressure and 125° 

2/ 8/32 — 30 minutes at 2 pounds’ pressure and 125° 

2/12/32- — 35 minutes at 2 pounds’ pressure and 125° 

The burns at this time showed a marked improvement, the necrotic membrane slough- 
ing out with very little bleeding. The vagina was packed after each treatment with 
vaselined gauze. 

This was left in until twenty-four hours before the next treatment, then removed and 
a cleansing bicarbonate of soda douche given. Treatments were further continued as 
follows : 

2/1G/32 — 40 minutes, 2 pounds’ pressure, 128° to 130° 

2/20/32 — 40 minutes, 2 pounds’ pressure, 128° to 130° 

3/ 3/32 — 35 minutes, 2 pounds’ pressure, 128° to 130° 

3/15/32 — 30 minutes, 2 pounds’ pressure, 128° to 130° 

Total treatments eleven, over a period of two months. 


Following the last treatment, the vagina presented a normal appearance. Not only 
was the slough gone, w'ith the attendant discharge, but the pain for which she presented 
herself and the leucorrhea had also been completely relieved. When seen again in May, 
she felt completely well and had no symptoms or discharge. The vagina, by inspection 
and palpation, seemed normal. 

Case 2. — (E. G. W.) Mrs. E. W., twenty-eight years of age, married three years. 
One pregnancy, terminating in a spontaneous abortion at eighth week, two years ago. 

Early in December, 1931, patient noticed an inflammation near the introitus, which 
became steadily worse. There was persistent pain of a throbbing nature, with an as- 
sociated thick, greenish-white leucorrheal discharge, moderate terminal dysuria, fre- 
quency, and marked vulva edema. 

A diagnosis of acute Bartholinitis, probably gonorrheal, was made, although re- 
peated smears from both glands and cervix were negative for gonococci. She was given 
symptomatic treatment and hot wet dressings applied. Ten day bed rest and local 
treatment of a conservative nature alleviated pain and swelling. By December 26 the 
swelling was practically impalpable, but some vaginal discharge persisted. Uterus and 
adnexa were normal except for moderate symptomless enlargement of right ovary. 

Because of the persistence of the discharge, with associated Bartholinitis, a series of 
Elliott treatments were begun, as follows : 


Dec. 29 — 35 minutes at 2 pounds’ pressure-distention. 
Jan. 2 — 40 minutes at 2 pounds’ pressure-distention. 
Jan. 9 — 60 minutes at 2 pounds’ pressure-distention. 
Jan. 14 — 60 minutes at 2 pounds’ pressure-distention. 


128° to 130° 
128° to 130° 
128° to 130° 
128° to 130° 


Following the last treatment, the patient complained of soreness. Examination 5 
days later showed severe burns of the upper vagina with adhesions beginning to coapt the 
inflamed and gray membranous surfaces. The denser adhesions were divided January 
29 with the actual cautery, and Elliott treatments for 40 minutes at 120° continued, the 
vagina being packed after each treatment with sterile vaselined gauze. Treatments were 
given at four and five-day intervals. 



C0SGR0^^3 AND WATERS: ELEIOTT TREATMENT 


731 


By M.irch 17 the mucous surfaces had entirelj’ reformed and presented soft, smooth, 
pliable surfaces •with no evidence of the preexisting ulcers or divided tissues. 

Case 3. — '(S. A. C.)Eleanor G., aged thirty-eight, para is. Spontaneous delivery 
Oct. 5, 1931, at home. Kemained in bed nine or ten days; was up and about one week, 
when she became acutely ill. Seen in consultation Nov. 16, 1931 (forty-two days post- 
partum), with high fever, severe pain in left lower abdominal quadrant, persistent 
vomiting, chills and night sweats, rapid pulse, anxious expression, dehydration, signs of 
acute parametritis and pelvic peritonitis. Admitted to Margaret Hague Maternity 
Hospital Nov. 16, 1931. On admission temperature was lOS® ; pulse 100 to 120 ; respira- 
tions 24; urine was negative; blood: red blood cells 3,680,000; Hb 64 per cent; white 
blood cells 14,500. Sedimentation time eighteen minutes. Blood culture was negative. 

She received two Elliott treatments daily for ten days and one daily for eleven days, 
a total of thirty-one treatments over a period of t'wenty-one days, each of sixty minutes ’ 
duration at temperatures 120° to 130°. 

Patient ’s temperature reached normal on the ninth day after admission, and she was 
discharged on the twenty-first day, convalescent; pelvic signs had almost completely 
disappeared. The vagina and fornices felt boggy and siuollen, indicative of rather 
marked local reaction to the long continued heat, but there was no evidence of ulcera- 
tion or necrosis of the mucous membrane. 

On Feb. 5, 1932, approximately two months after her discharge from the hospital 
and discontinuance of Elliott treatment, she was seen at home, complaining of low'er 
abdominal distress and intense pain in the rectum, with rectal tenesmus. She had not 
had any visible menstrual discharge in the interim. 

Bimanual examination showed a complete occlusion of the vagina at about its mid- 
dle, with massive induration of the pelvic cellular tissue along the whole right side of 
the vagina. During the examination the finger penetrated the partly cicatrized occlud- 
ing barrier and there was a moderately copious discharge of viscidly fluid dark blood, 
which is believed to have been retained menstrual blood. 

Patient was referred to hospital for observation. Lipiodal injection showed only a 
narrow sinus connecting the upper and lower portions of the vagina. The uterine cavity 
was of normal contour, the uterus was pulled to the left, the right tube was partly filled, 
the left not at all. 

The constriction was progressively dilated at several sittings, using first Hegar’s 
uterine dilators, and then test tubes of graduated sizes. 

During this time there was some mild irregular fever, which gradually subsided. The 
patient’s subjective condition improved, and the pelvic inflammatory induration de- 
creased. She was discharged Feb. 18, 1932. 

On several subsequent ofiice examinations the degree of dilatation secured in the hos- 
pital was maintained, and menstruation was not further interfered with. At the last 
report. May 13, 1932, no peMc symptoms were complained of. 

Case 4. — (S. A. C.) Mary H., aged thirty, grav. 1. Delivered at St. Mary’s Hos- 
pital Nov. 18, 1931, in O. R. P., by Scanzoni maneuver. Two days later she showed what 
appeared to be a grippy infection characterized by a chill, infected throat, severe 
frontal headache, generalized muscular pains, rales throughout chest, and elevation of 
temperature to 103.2°. The following day her temperature, of the remittent type, 
reached 105.4° ; chest signs were indeterminate except for disseminated rales and there 
was unproductive cough. The lochia was very odorous and several clots were expelled. 
Her attendant still considered her infection influenzal in nature. 

This course continued without significant change, the daily temperature ranging 
from 102.8° to 104.6° until Dec. 3, 1931, the fifteenth postpartum day, when she was 
first seen in consultation. 

Physical findings at this time indicated an acute bilateral parametritis, with localized 
peritonitis. Pulmonary findings were essentially negative, which x-ray on this date con- 



732 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


firmed. Two days afterward, temperature again reached 105.4°, and later on this day 
the first Elliott treatment was given. They were continued at intervals of twice a day, 
for sixty minutes ' duration, at temperatures up to 130° E., for thirty-one days. During 
this interval patient progressed to a fairly satisfactory convalescence, the temperature 
becoming normal on the fifty-fifth day. She was discharged Jan, 16, 1932, on the fifty- 
ninth postpartum day. At this time x-ray findings in the lungs were entirely negative 
except for some slight diffuse increase in density of markings. 

One of us saw her in her home about two weeks after her discharge from the hospital, 
and noting some narrowing of the vagina, warned her attendant to watch for further 
atresia. 

She was again referred in consultation April 1, 1932, two and one-half months after 
the last Elliott treatment. She had not menstruated and complained of severely pain- 
ful sense of pelvic tension and rectal pressure. 

At about the level of the junction of the lower and middle thirds of the vagina, there 
was complete atresia apparentlj' b}' transverse agglutination of the anterior and pos- 
terior vaginal walls. A little to the left of the midline was a tiny exfoliation of what 
looked like granulation tissue. A slender forceps was readily forced through the ob- 
struction at this point, whereupon there was an immediate gush of thick brownish-red 
material evidently representing an old accumulation of blood. It was not foul, nor 
clotted. It continued to exude to a total amount of more than 500 c.c. and some dis- 
charge continued for several hours after she left the office. 

At subsequent sittings the opening was gradually dilated to a diameter of 3 to 4 cm. 
During this period she had a normal menstruation. 

In May, 1932, she removed from the locality, and no further report has been obtained. 

SUMMARY AND COMMENT 

1. Four eases are presented, of damage to the vaginal mucosa believed 
to be directly due to tlie Elliott treatment. Two had definite burns of the 
upper vagina, one of which showed beginning adhesions w^hicli would al- 
most certainly liave progi'essed to permanent atresia, if not detected and 
treated. Two showed complete occlusion of the vagina by cicatricial atresia 
undoubtedly due to original damage similar to tliat noted in the first two. 

2. These eases are reported without prejudice to the value of the method, 
but with the warning that regular careful inspection of the parts should 
be maintained during any course of such treatments and the suggestion 
that the frequency and duration of the latter be regulated by the reaction 
of the tissues involved. 

264 Union Street. 

39 Gifford Avenue. 

ABSTRACT OE DISCUSSION 

DR. E. C. HOLDEN. — ^We have been using the Elliott treatment in Bellevue Hospital 
since November, 1929, and have been very favorably impressed with the results obtained. 
However, it is not the value of the Elliott treatment which is under discussion at present. 
Approximately 10,000 treatments have been given, by three nurses, who were well 
trained in the technic. One slight burn occurred at a time when we had a substitute 
nurse. Treatments in this case were given daily, using moderate distention, and temper- 
ature of 120°, and rapid and complete healing resulted. 

"We think it is well to use moderate distention and a moderate degree of temperature 
in patients past middle life, especially where there is an atrophic condition of the vagina. 
In all patients, the vagina should be examined before each subsequent treatment to note 
the condition of the tissues. The distention used, should always be borne -with comfort 



LIFVENDAHL: TUBAL PREGNANCY 


733 


by the patient, and the temperature during treatment should be raised only three-quar- 
ters of a degree per minute. 

Our conclusion, based upon this large series of treatments is, that when the proper 
technic is used, we feel it is impossible to get a burn severe enough to cause any damage 
of the vaginal mucosa. 

DE. H. F. GEAHAM . — 'We have used the treatment in about GOO cases. The worst 
burn was in the third treatment given by an interne before we had a trained technician, 
and he distended the bag to about four pounds, kept the temperature at 130° and went 
away in spite of the complaints of the patient, because he understood that was the way 
to give the treatment. In that case there was a slough about an inch and a half in diam- 
eter which took twelve or fourteen days to heal completely. 

DE. S. A. COSGEOVE. — Dr. Holden has touched indirectly on the purpose of pre- 
senting these cases. He has said that in his experience they have had only one or two 
minor burns because the treatments have been given by experts specially trained. It is 
not to be conceived that any method can be offered to the profession and have every- 
body that uses it as expert as Dr. Holden 's operators are, and therein lies the value of 
the warning that some very unpleasant results may occur from the use of this procedure. 


TUBAL PREGNANCY FOLLOWING UTERINE INSEMINATION*' 

R. A. Lipvendahl, M.D., Chicago, III. 

(From the Bepartvient of Gynecology of the Post Graduate Hospital and 

Medical School) 

A REVIEW of the available literature for the last twelve years does not 
elicit a single case of tubal pregnancy following artificial insemina- 
tion for the relief of sterilitjL That other gjuiecologic procedures, par- 
ticularly of a diagnostic character, have been followed by pregnancy is 
confirmed by Rubin d In 1929 he reported 205 cases of pregnancy out of 
2000 eases in which he had done uterotubal insufflation for infertility. In 
3 of these 205 cases the pregnancy was located in the fallopian tube. Since 
this article concerns the question of infertility the discussion is not cen- 
tered about the subject of ‘ ‘ induced” tubal pregnancy. The same author,^ 
in another writing, regarding the most favorable time for tubal insuffla- 
tion, states that there is less possibility of displacing an impregnated ovum 
from the uterine cavity if the patency test of the fallopian tubes is done 
about one week after menstruation. In our patient, uterotubal insuffla- 
tion was performed, but the procedure was done some time before artificial 
insemination, and evidently has very little, if any, import in this case. 

Untoward results have included those conditions attended with perform- 
ing the Rubin test, plus the possibility of carrying infected material into 
the uterus, fallopian tubes, or peritoneal cavity. Before performing the 
procedure, the above possible complications should be kept in mind. 
Trauma of the endometrium can occur with the possibility of gas embolism 
and collapse and even death is apt to take place if the method is not used at 
the proper time has been sufficiently emphasized by Rubin.^ Also, he has 
described adequately the subject of dislocation of the endometrium 


Presented before tbe Chicago Gynecological Society, December 16, 1932. 



734 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


tlirougli tile fallopian tubes ivitli resultant endometriosis of the adjacent 
pelvic structures. Infection of tbe fallopian tubes and pelvic structures 
can occur as the result of several errors in technic or the presence of infec- 
tion in the genital tract of the male or female. If a specimen is obtained 
from a container that is not aseptic or if infected from the vagina, the 
bacteria from these sources can readily produce infection along the course 
of the genital tract. The folloAving case is of considerable interest because 
of presenting none of the above mentioned complications. 

CASE REPORT 

White patient, twenty-four years of age, entered the clinic on Jan. 10, 1931, because 
of a yellowish-white vaginal discharge which came from an " eroded and cystic cervix. 
Linear cauterization was performed on Jan. 12, 1931, and by Eeburary 7 of the same 
year the treated area was healed and there was no discharge, except for a small amount 
of clear mucus from the cervical canal. On Jan. 12, 1931, she presented the question of 
steriUt}’ but was advised to wait until the cervi.v healed before performing any tests. 
She had been married in August, 1925, and one year and nine months later had an un- 
complicated delivery. For two j’cars after this they practiced coitus interruptus; but 
for over three years contraceptive precautions had not been taken. Menstruation be- 
gan at thirteen 3 mars of age, was regular until marriage, and since had been irregular, 
with bleeding occurring every three to six weeks, six to seven days ’ duration, moderate 
in amount, and accompanied with moderate lower abdominal cramps. She described 
herself as a “ spitter ’ ’ in that the semen was always discharged following intercourse. 
Examination at this time showed a relaxed "leva ter sling” and a slight cystocele. A 
Eubin test performed on Feb. 17, 1931, showed patency of the tubes. The next day a 
eolpoperineoplastic operation was performed. After this had firmly healed, intercourse 
was indulged in on an average of tvico a week for a period of nine months. On Dec. 6, 
1931, a one-hour old vaginal “puddle” specimen of live spermatozoa was injected into 
a normal appearing cervical os bj' means of a bulb-syringe, under moderate pressure. 
No coitus following uterine insemination until January 10, and she had not indulged 
since her last menstruation on November 23, two days following the premous menstru- 
ation, which ended on Nov. 2, 1931. Seven weeks later she had not menstruated, com- 
plained of pain and fuUness of the breasts, and pain in the left lower quadrant. The 
latter symptom had been repeatedlj'^ present before and was regarded as being due to a 
spastic sigmoid. At this time the uterus was very slightly enlarged, firm throughout 
but colostrum was expressed from the nipples. Three weeks later she stated that she 
had been nauseated and vomited daily for a period of two to three weeks. The pain in 
the left lower quadrant had been especially severe, seventeen days after the insemina- 
tion, on Dec. 23 and 25, 1931. On examination at this time (Feb. 13, 1932) the find- 
ings were the same as of seven weeks following the insemination, but in addition the 
body of the uterus was softer and to the left of it was a tender mass twice the size of a 
normal ovary. No vaginal bleeding had occurred. On Feb. 23, 1932 she acquired a 
“severe cold,” with a temperature of 104°, and on the twentj'-sixth of the same month 
began to bleed profusely from the vagina. Examination, three days later, showed a 
3 by 5 cm. boggj- and tender mass, which had been noted ten days previous. The cul- 
desac was free of anj' mass or exudate. Bleeding continued from the vagina until she 
was again seen on March 12, when the findings were the same. This period of observa- 
tion was permitted because of the possibility of an aborting intrauterine pregnancy, 
associated with a cyst of the left ovary. The latter periodic swellings of the left ovary 
had been noted in her on one occasion before the insemination had been performed. 
Although the test for pregnancy was positive, in this case it was of no help. But since 
no fetal or placental tissue had been passed, laparotomj' was advised. 



LACKNER AND KROHN : TERATOMA OF UTERUS 


735 


On March 14, 1932, thirteen weeks after uterine insemination, preliminary curette- 
ment yielded a moderate amount of thin and slightly thickened endometrium of a yel- 
low and red to purple color. 

Before opening the peritoneum through the Pfannenstiel incision, small dark purple 
1 to 2 cm. pieces of clots were seen through the peritoneum and the latter were also 
found between the loops of the ileum. Exploration of the pelvic organs revealed the 
following: The uterus was 1% times normal size, anteverted, and moveable. The left 
fallopian tube was adherent to the posterior aspect of the corresponding broad liga- 
ment and ovary by moderatelj’ firm purplish adhesions that were easily freed, permit- 
ting the tube to be delivered. The distal one-half of the tube presented a fusiform in- 
tact purple colored swelling, having a diameter of 4 cm. in its ampullar portion and 
tapering towards the fimbriated end where its diameter was 2.3 cm. Lying in the open- 
ing of the fimbriated end of the tube enmeshed and held there by dark clotted blood was 
an 8 cm. long pale yellow embryo. The right fallopian tube and ovary were grossly 
normal. The left tube was removed. 

The possibility of the pregnancy having occurred before the artificial 
insemination is rather remote because of the size of the embryo, the onset 
of clinical symptoms and fiLndings and her inability to become pregnant be- 
fore the artificial insemination had been done. The Rubin test had been 
done nine months before the insemination, so she should have had suffici- 
ent opportunity to become pregnant if the insufflation of the tubes had 
opened them. Furthermore, no findings were noted when the injection 
was done to indicate that the tubes had ever been closed. 

That the infected cervical mucous discharge probably prohibited her 
from becoming pregnant previous to the cauterization of the cervix uteri 
is very likely. Against this is the fact that the discharge from the cervical 
canal had been grossly noi-mal for a period of eight months before insemi- 
nation was resorted to. 


ABSTRACT OP DISCUSSION 

DR. MARK T. GOLDSTINE. — I have noted five cases of very severe pelvic infection 
following insemination, one requiring the removal of a large abscess of the ovary. We 
feel this is a rather dangerous thing to do. 


REPORT OP A CASE OP TERATOMA OP THE UTERUS- 
Julius E. Lackner, M.D., and Leon Krohn, M.D., Chicago, III. 

(From the Departments of Gynecology and Pathology of the Michael Reese Hospital) 

'^ERATOMAS are defined by Ewing*^ as a group of tumors composed of 
recognizable tissues and complex organs derived from more than one 
germ layer. Although teratomas have a distinct predilection for the sex 
glands, their occurrence in the uterus is an extreme rarity. A review of 
the literature revealed only very few cases of teratoma of the uterus, the 
majority of which are of questionable authenticity. Robert Meyer- em- 
phasizes the fact that one must make a diagnosis of termatoma of the 
uterus with extreme caution. 

‘Read before the Chicago Gynecological Society, November 18, 1932. 



736 


AiLERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGT^ 


Tlie majority of tumors described as teratomas of tbe uterus were orig- 
inally teratomas of the ovary which, because of inflammation, became ad- 
herent to the uterus. Eventually they perforated the wall of the uterus 
and became intrauterine tumors. 

However, two authentic cases were reported recently. ]\Iann described 
a teratoma embryonale situated in the left horn of the uterus which con- 
tained derivatives of the three germ layers. Hellendall’s case was an 
intramural teratoma of the corpus uteri which perforated into the uterine 
cavity and discharged hair through the vagina. There are many other 
cases on record which cannot be accepted as true teratomas of the uterus. 

REPORT OP CASE 

The purpose of this communication is to report a teratoma of the uterus. 
The tumor was attached to the internal os and projected through the 
cervical canal (Fig. 1) in the form of a poljTioid growth. The essential 
details of the case are as follows : 

Mrs. H. H., aged tliirtj--four, entered Michael Reese Hospital Dec. 7, 1931, with the 
complaint of vaginal bleeding of fourteen weeks’ duration. She had been married for 
sixteen years, and liad two normal fullterm deliveries, the first in 1916, and the second 
in 1918. Her menstrual periods were verj- irregular, the interval varying from four- 
teen to sixty days, the duration from two to eight days, and the amount of flow from 
2 to 20 pads. During the latter part of May, 1931, she liad a seven day period. Since 
tlien she had been flowing almost continuously, using a pad each da}'. On August 26, 
1931, the vaginal bleeding increased and resembled a normal period. The patient 
suffered from cramps which were drawing in character and occurred every two or three 
minutes. She expelled a mass from the vagina which she described as a hard lump 2% 
inches long. The bleeding subsided and recurred two weeks later continuing from the 
middle of September to the time of her entrance into the hospital on December 7, 1931. 

The gynecologic examination made Dec. 7, 1931, was as follows: The atrium was 
multiparous. The cervix was badly lacerated and soft. The external os admitted a 
finger tip. The corpus was slightly enlarged, anteflexed, freely movable, and not sen- 
sitive. The adnexa were normal. A diagnosis of incomplete abortion was made and 
on the following day a dilatation and curettage were performed. The tissue obtained 
was diagnosed as endometrial polyp rvith endometrial h}'perplasia. The patient made 
an uneventful recovery and was discharged from the hospital Dec. 13, 1931. 

On Feb. 23, 1932, the patient was admitted to the service of the senior author be- 
cause of continued vaginal bleeding since her discharge from the hospital. Vaginal 
examination at this time revealed a pedunculated tumor about 4 cm. in diameter, pro- 
truding from a dilated cervix. The surface of the tumor was irregular and the con- 
sistency of the tumor was soft. The corpus and adnexa were negative. 

A biopsy was performed on Feb. 27, 1932. Since the exact nature of the tumor was 
not established by frozen section, it w'as deemed advisable to remove the uterus. A 
vaginal hysterectomy was done. The ovaries and tubes were normal and were left in- 
tact. The patient made an uneventful recovery and was discharged on March 10, 1932. 

The pathologic report was as follows : 

The specimen consisted of a symmetrical, previously opened uterus 12 by 5 by 4 cm. 
in its greatest diameter (Fig. 1). The myometrium averaged 1.5 cm. in thickness. 
The endometrium averaged 1 mm. in thickness; it was granular and hemorrhagically 
discolored, A 1 cm, circumscribed, firm, fibrillar intramural nodule typical of a myo- 
fibroma was present in the fundus. Attached to the cervical mucosa, about 3 cm. 
above the external os, was an irregular, nodular grey-white mass measuring 4 cm. in 



LACKNER AND KROHN : TERATOMA OF UTERUS 


737 


diameter. It was of firm consistency but contained several cysts measnring up to 1 
cm. in diameter. These cysts were filled with a viscid opalescent flnid. The tumor 
projected into and dilated the cervical canal. The tnmor was easily movable. The 
area of attachment was rouglily circular and measured 1.5 cm. in diameter. 



Fig. 1. — Gross specimen of opened uterus illusti'ating position of tumor. 



Fig. 2. — Detail of cartilage and mucoserous glands. (xlOO.) 


Histologic examination: The wall of the cervix at the point of attachment of the 
nodular mass was only partially covered by epithelium. On other portions of the 
tumor the epithelium was absent and replaced by fatty tissue and small bundles of 
smooth muscle fibers. At the lower portion of tlie tumor the epitlielium consisted of 



738 


AMERICAN journal, OP OBSTETRICS AND GYNECOLOGY 


cervical lining cells. The nodnlar mass itself is made up of a great variety of epithelial 
and connective tissue structures. In various sections, cartilage (Pig. 2), smooth 
muscle, myxomatous tissue, fatty tissue, ganglion cells, peripheral nerve fibers, 
squamous epithelium rvitli sebaceous glands, hair follicles, occasional sweat glands 



Pig. 3. — Haphazard groupings o£ squamous epithelium, hair follicles, sebaceous glands, 
and atrophic sweat gland structures, suiTounded by adipose and fibrous tissue. (x60.) 



Fig. 4. — ^Lower power view of dermoid structures shown in Fig. 3, demonstrating 
contiguity ■with epithelial structures of intestinal type. (x20.) 

(Figs. 3 and 4), pseudostratified columnar ciliated epithelium resembling the nasal 
mucosa, and epithelium of the bronchial type (Fig. 5) ure identified. In addition, 
there is a tendency toward an organoid arrangement of tissue elements (Figs. 5 and 6). 
Structures which can be identified as intestines are found (Fig. 6). In these, the 



LACKNER AND KROHN : TERATOMA OP UTERUS 


739 


epithelium contauis many goblet cells and form crypts identical with the crypts of 
Lieberhiihn. In the depths of these crypts, tj’pical Paneth cells are found in large 
numbers. Beneath there is abundant lymphoid tissue reproducing the structures of the 
lymphoid follicles of the intestines. Cartilage and cylindrical epithelial structures 
are found in arrangements suggesting very strongly broncliial structures (Fig. 5). In 
short, derivatives of all germ layers .are found; organoid intestinal and respiratory 



Fig. 5. — Ciliated columnar epithelium, cartilage and mucoserous glands reproducing the 
aspect of a bronchial wail. (x250.) 



Fig, 6. — Structures recognizable as small intestine, "with longitudinal and circular 
muscle bundles, lymphoid follicles and typical intestinal mucosa, (x40.) 


structures representing entoderm; cartilage, smooth muscle and fat tissue representing 
mesoderm ; and skin with its derivatives as well as ganglion cells and peripheral nerve 
fibers representing ectoderm. In all sections, careful search fails to reveal the pres- 
ence of any structures whose origin can be attributed to fetal membranes. The diag- 
nosis of the tumor was teratoma of the uterus with attachment to the internal os, pro- 
jecting in the form of a polypoid structure through the cervical canal. There was also 
a myofibroma of the uterus. 







740 


AMERICAN JOURNAL OR OBSTETRICS AND GYNECOLOGY 


DISCUSSION 

This ease is reported because of the rarity of true teratoma of the uterus 
and the difficulty in diagnosing these tumors. The tumor described rep- 
resents derivatives of the three germ layers and is attached at the internal 
os. The presence of two normal ovaries and two normal tubes exclude the 
possibility of a teratoma of the ovary or tube becoming adherent to the 
uterine wall, perforating it, and thus becoming an intrauterine tei-atoma. 

The question naturally arises as to whether the case reported here is 
a true teratoma, or whether it is a part of an embryo transplanted to the 
region of the internal os after an incomplete abortion. We must also 
consider the possibility of a cervical pregnancy or even a twin parasitic 
growth. It is impossible to make a definite diagnosis in spite of the fact 
that the histologic picture of this tumor answers all the qualifications in- 
cluded in the definition of a teratoma. It is conceivable that the patient 
was pregnant and aborted incompletely. Some of the remaining tissues 
of the embryo may have been implanted in the cervix with subsequent 
tumor formation. In favor of such an assumption is the fact that at the 
time the patient was first seen a dilatation and curettage were performed 
and the tumor was not detected. When the patient returned to the hos- 
pital two and one-half months later, a tumor was found protruding 
through the cervical canal. This rapidity of groAvth is probably more 
suggestive of implantation of tissue from a pregnancy than of a true ter- 
atoma. It is probable that at the time the patient was first curetted, the 
tumor Avas present and aa'bs overlooked. On the other hand, there is no 
proof that the patient Avas pregnant. Tlie scrapings from the uterine 
cavity shoived no evidence of a pregnancy but AA'ere diagnosed as endo- 
metrial polyp Avith endometrial hyperplasia. The fact that no decidual 
tissue was found does not rule out a pregnancy, because the decidual tissue 
could have been absorbed in the period AAdiich elapsed from the time the 
possible abortion occurred until tlie curettement was performed. One 
cannot assume from the history alone that a pregnancy had existed, par- 
ticularly since the menstrual periods Avere ahimys irregular. 

After due consideration of these possibilities, we feel that the ease here 
presented is a true teratoma of the uterus. Almost any case diagnosed 
as teratoma of the uterus is open to some of the criticism A'^entured here. 
We are aAvare of the fact that one must make a diagnosis of teratoma of the 
uterus only Aifiien every other possibility is ruled out. 

REFERENCES 

(1) Ewing, James: Neoplastic Diseases, ed. 3, 1014, 1928. (2) Meyer, Eobert: 

Teratome des Uterus, Henkel-Lubarscli 7 : 537, 1930. (3) Graves, William P.: Gyne- 
cology, ed. 4, 508, 1928. (4) Wilms, M.: Beitr. z. Patli. Anat. 19; 367, 1896. (5) 

Ashanasy, If.; Verhandl. d. Deut. Path. Ges., p. 58-76, 1906. (6) Kiwiscli, F. A.: 

Klinische Vortrage tiber die Krankheiten der Gebarmutter, ed. 3, p. 426. (7) Wagner, 

E.: Von den Gesclnvulsten der Gebarmutter, Arch. Heilk. N. P. 1 P. 247, 1857. (8) 

Lee, Th. S. : Von den Geschwulsten der Gebarmutter und der iibrigen AVeiblichen Gesoh- 
lechtsteile. Alls, dem Engl, iibersetzt. Berlin: A. Porstner P. 40, 1847. (9) Lehert, S.: 
Gaz. Med. 52: 808, 1852. (10) de Sinety, L.: Manuel pratique de gynecol. et des 



LACKNER AND KROHN : TERATOMA OF UTERUS 


741 


malad. des Eemmes, Paris, p. 472, 1879. (11) Shoemaker, G. E.: Am. J. Obst. 33: 

859, 1896. (12) Mann, TV.: Virchows Arch. f. Path. Aiiat. 273: 663, 1929. (13) 

(13) Ecllendall, Hugo: Zentralbl. f. Gyniik. 54: 2398, 1930. (14) Kovacs, F.: 

Orvosi Hetil 75: 301, 1931. (15) Schroeder, E., and Hillejalin, A.: Zentralbl. f. 

Gyniik. 44: 1050, 1920. (16) Penkert, M.: Beitr. z. Geburtsh. u. Gyniik. 9: 448-449, 

1905. (17) Lockycr, C.: Proc. Boy. Soc. Med. London 45: 93-97, 1912-1913. 

104 South Michigan Avenue. 

ABSTRACT OF DISCUSSION 

DR. OTTO SAPHIR. — One very important question presents itself, namely : is this 
a true teratoma or does the tumor consist of portions of a fetus implanted in the region 
of the internal os? The history revealed an abortion in August which clinically was 
not diagnosed until December when the patient entered the hospital for the first time. 
At this time the patient was curetted but the tumor was not recognized. As a matter 
of fact the tumor was not discovered until two and one-half months later at the final 
operation. 

The history of an abortion is in favor of the tumor being part of a fetus. Also the 
fact that the tumor was not seen at the curettage is in tliis favor. The histologic find- 
ings of whole organs such as intestinal wall with mucosa, submucosa and muscularis, 
and trachea with mucosa, submucosa, mucous glands and cartilage, speak more or less 
against teratoma. The relative age of the fetus could very well be six months which 
would correspond exactly to the history. 

In favor of this being a teratoma is the location of the tumor, its pedunculated ap- 
pearance, and probably the absence of testicular and ovarian structures. But if this is 
a teratoma, it must be conceded that the tumor was missed at the curettage, because 
I do not believe that a teratoma could have attained this size in two and one-half 
months. 

What do wc mean by teratoma? Most of the textbooks define a teratoma as a tumor 
which consists of representatives of three germinal layers which are present in dis- 
orderly fashion. Such a definition -would very well fit this tumor -with the possible 
exception that we are not dealing just with representatives of three germinal layers, 
but also -with formations of organs. 

It is possible that during the curettage a portion of a fetus -was displaced and im- 
planted in the region of the internal os. 

DR. LESLIE BRAINERD AEEY. — Looking objectively at a slide shows one thing, 
while reading the history into the same slide will sometimes tell another story. So far 
as the microscopic preparations go, I see no reason how one could avoid calling the 
present specimen a teratoma. Certainly the organoid arrangements, tlie appearance of 
poorly organized bronchial-like structure, the intestine, and so on, are the things that 
are repeatedly described in teratoma in other locations where fetal implantation would 
seemingly be excluded. In what are called teratomatous masses, of course, we are 
probably including a variety of things because there are all gradations between twins 
of the asymmetrical type and fetus in fetu, as well as things of quite different nature, 
like giant cysts of primitive streak origin, teratomatous masses inside the body of the 
type shown here. Whether one is always discussing a homogeneous type or is some- 
times including under the same pathology different categories of things is often qnes- 
tionable. 

As the result of all the newer knowledge we are still just where -we were in the in- 
terpretation of teratomas. Furthermore, there seems to be no immediate escape from 
this dilemma without the development of some line of attack which will produce new 
and convincing information as to what its pathogenesis really is. 

DR. N. S. HEANEY. — I do not think too much weight should be given to the fact 
that no tumor was discovered at the time of the curettage. Clinical e-vidences would 



742 


AJIERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGT- 


seem to point to the fact that the tumor was present at that time. A curcttement was 
performed and the symptoms for which she was operated upon continued witliont abate- 
ment and at a iater time, wdien operated upon, the tumor was found. I believe the 
tumor was there at the time of the first operation. We see this frequently in cases of 
intrauterine pedunculated fibroids where a curettage is done and subsequently the 
uterus gives birth to the fibroid. 

DE. JOSEPH L. BAEE. — A negative point that might have some bearing on the 
decision is the thought that if fetal implantation W'ere the basis of this tumor, then 
fetal implants ought to be found very much more frequently tlian they are. In the 
vast number of abortions that take place in this and other communities, many of which 
are incomplete, in many of which fetal structures are left, and in many of which the 
uterine mucosa is traumatized, there should be a greater frequency of fetal implanta- 
tions than we actually see or hear reported. The extreme rarity of this lesion may add 
to the argument that the specimen is a true teratoma. 

DE. EEEDEEICK PALLS. — Eegarding the rapidity of growth in teratoma, a pa- 
tient came under my observation about three years ago at Cook County. This patient 
had a hysterectomy performed by Dr. Schmitz for a fibroid. He left one ovary after 
a supracervical hysterectomy. Within six months the woman returned to the County 
Hospital with a tumor about as large as a baseball. I operated and removed a teratoma 
arising in the ovarj’ which Dr. Schmitz had left. That tumor was at least 10 cm. 
across, so it seems to me that this tumor could easily have grown in the length of time 
between the two operations. I should Eke to ask Dr. Lackner if any of the tumor 
cells showed evidence of malignancy. 

DE. KEOHN (closing). — Since the histogenesis of teratomas is still a matter of 
conjecture, and the subject of teratomas is so broad, onlj’ a few of the more important 
issues involved in this case can be discussed at this time. Dr. Baphir favors the diag- 
nosis of fetal implantation because, in the first place, he assumes that the patient was 
pregnant and aborted incompletely in August, 1931, and secondly, because of the pres- 
ences of organoid intestinal and respiratory structures in the microscopic sections. In 
ansu'er to the first assumption, there is no evidence in the history of the existence of a 
pregnancy. As Dr. Lackner has already stated, the patient 's menstrual periods were 
always irregular. At the time the curettage was performed, no products of a pre- 
existing pregnancy were found. The tumor was probably present at this time and 
overlooked. The instrumental dilatation of the cervix could have been sufficient to aid 
the passage of the pedimculated tumor through the cervical canal so that when the 
patient returned to the hospital two and one-half months later, it protruded through 
the external os. No sharp line of demarcation can be drawn between the histologic 
picture of teratomas and fetal implantations. The presence of organoid intestinal 
and respiratory structures do not speak against the diagnosis of teratoma if we are to 
accept the definition of these tumors given by Ewing ; that they are a group of tumors 
composed of recognizable tissues and complex organs derived from more than one 
germ layer. MacCullum describes teratomas as rudimentary organ-like masses of 
tissues mingled together in an xmsuccessful attempt to form a fetus. In teratomas 
there is a mixture of fetal tissues in disorderly arrangement. In fetal implantations, 
one would expect to find organs in nearly normal relations. Lexer collected seventeen 
cases of fetal implantations in the abdomen in which he found rudimentary limbs, 
organs, and well formed membranes and umbilical cords. These were not found in the 
case presented here. On the other hand, numerous teratomas have been found to con- 
tain intestinal organs. In a personal communication with Dr. Jaffe, he expressed the 
opinion that this tumor is a teratoma or tridermoma after having studied the case 
and having examined the sections. He believed that the tumor arose from the wall of 
the uterus since both ovaries and tubes were normal and there were no adhesions about 



LEVY AND TRIPOLI: GUMMAS OE BLADDER 


743 


the uterus. Because of all these facts mentioned, “we believe this tumor to be a tera- 
toma of the uterus and that fetal implantation is a remote possibility. 

In answer to Dr. Pall’s question, there was no evidence of malignancy in the micro- 
scopic sections and also there was no invasion of the tumor into the uterus. 


GUMMAS OF THE URINARY BLADDER 
Walter E. Levy, M.D., and Carl J. Tripoli, M.D., New Orleans, La. 

(From the Department of Gynecology and Department of Fathology, Charity Sospital) 

S yphilis, manifesting itself in the tertiary stage (gummas) and involving the 
genitourinary tract, especially the urinary bladder, is of interest, not only as re- 
gards its rarity, but also as regards the difficulties in making an accurate diagnosis. 
The salient facts uiDon Avhich a diagnosis is usually made are : a history of syphilis, the 
positive complement fixation test, and the cystoscopic findings. 

A rather extensive review of the literature has not revealed a similar case, wherein 
it was possible to make such a detailed microscopic examination as in this one. In view 
of this, the following ease is believed to be of sufficient interest to warrant reporting. 

The patient, a colored female of twenty years, was admitted to Charity Hospital on 
March 27, 1931, ivith a history of pain in the lower abdomen, and a leucorrheal dis- 
charge. She had had the discharge for the past year, and this and the pain date back to 
an abortion about that time. Her past history, other than this, was irrelevant, and her 
general physical examination was negative. She did not complain of any pain or burn- 
ing upon urination, or any urinary frequency. 

Vaginal examination revealed a cervix which was slightly lacerated, and the seat of 
a mild endoeervicitis. The uterus was anteflexed and fixed. There was tenderness in 
both tuboovarian regions, and on the light side, an ovarian cyst, about the size of an 
orange, approximately 8 cm., could be palpated. 

The Wassermann reaction was strongly positive. Two injections of neoarsphen- 
amine, 0.4 gm. each were given at an interval of seven days, prior to operation. 

The urine, a voided specimen, examined before operation, revealed nothing of note 
except for an occasional pus cell and a few epithelial cells. There were no red blood 
cells present. The total white blood cell count was 13,400 c.mm., and the differential 
count showed a slight relative and absolute neutrophilic increase. The patient’s tem- 
perature was normal the entire time before the operation. 

The preoperative diagnosis was, lacerated cervix, chronic salpingitis, and right 
ovarian cyst; tertiary syphilis. 

The patient was operated upon on April 6, 1931, under ether anesthesia. The ab- 
domen was opened in the mid-line between the umbilicus and the symphysis pubis. An 
ovarian cyst, about 8 cm, in size, on a pedicle, was found on the right side, and was 
easily removed. Microscopic examination revealed a simple polycystic oophoritis. The 
tubes showed slight thickening but were not removed. The left ovary was normal. The 
bladder on the left side was markedly thickened and had a flat tumor mass in its wall. 
The mass was about 5 cm. in diameter and about 1 cm. in thickness, pinkish grey in 
color, and adherent to the left half of the corpus uteri. In attempting to free this by 
blunt dissection, the mass was penetrated, and a considerable quantity of necrotic ma- 
terial escaped. Fearing that the bladder might have been entered, a glass catheter was 
passed by an assistant through the urethra, and in turn presented at the puncture wound. 
It was decided to explore further, and the peritoneum to the side of the bladder and 
uterus was opened, and on careful examination, this necrotic mass was found to extend 
down to the left iliac vessels. 

The wall of the bladder adjacent to the necrotic mass was hard and friable. The 



744 


AJIERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


rent in the bladder was closed wtli interrupted linen sutures. The opening was further 
sealed by suturing the fundus of the uterus over it, and then the left round ligament 
was in turn brought over this suture line. A piece of rubber tissue and a cigarette 
drain were put in, and the abdomen was routinely closed. An indwelling catheter was 
inserted into the bladder. The patient left the operating table in fairly good condition. 

On the third postoperative day, the patient started to have a temperature which 
ranged from 100.5° to 102° for the next three weeks. During this time she appeared 
dull and apathetic. 

About one week following the operation, she developed a suprapubic urinary fistula. 

After about the third week, perhaps as a result of intensive syphilitic treatment, the 
patient improved a bit. 

On May 5, 1931, the patient was cystoscoped (Dr. Beacham). The report of the 
cystoscopist was: "Cj’stoscope introduced easily. Bladder contracted udth pressure 
deformity on the right side. On the left side, posteriorlj'' is a fistulous tract that drains 



Fig. 1. — High power 60x. Illustrating endarteritis with thrombosis and perivascular 

lymphocytic infiltration. 

through a suprapubic fistula. Prom the history, operation and examination, the condi- 
tion is one of sloughing gumma of the bladder. ’ ’ 

The remainder of the course was one of a steady decline, and on June 7, the patient 
died; two months after the operation. 

Only a partial necropsy was possible, by means of opening the subumbilical laparot- 
omy incision. There was a diffuse filmo-purulent generalized peritonitis, most marked 
in the pelvis. The urinary bladder and tubes and ovaries were matted together in the 
inflammatory exudate. The bladder was contracted doivn, and upon its removal was 
opened. A small amount of purulent urine was present. The mucosa was markedly in 
flamed and pinkish in color. Diffusely distributed over the bladder mucosa, were 
whitish plaques, irregular in contour and ranging from 2 mm. to 1 cm. in diameter. In 
the upper right cornu of the bladder there was a tumor mass cohered over bj acute in 
flammatory exudate. On opening the mass, it was firm in consistency, j ellowish-white 
in color mth a central area of necrosis. 







LEVY AND TRIPOLI: GUMMAS OP BLADDER 


745 


Mici'oscopie examination revealed the blood vessels markedly thickened, accom- 
panied by endarteritis with thrombosis and perivascular lymphocytic infiltration. 
There was a diffused slight fibrosis with lymphocytic infiltration and a few neutrophilic 
leucocytes scattered. Here and tliere small areas of necrosis with an occasional multi- 
nucleated giant cell was present. (Pigs. 1 and 2.) 

It is singular, in reviewing the literature, how really little is said concerning gumma 
of the bladder. Keyes’ does not mention it in his textbook ; neither does Morton.’ B. C. 
Corbus,® writing in Cabot’s “Modern Urology,’’ makes the statement that “Syphilitic 
lesions of the bladder are scarcely known, ’ ’ and most works on urology and syphilology, 
fail to make mention of the subject. Lowsle 3 ' and Kerwin,’ state that for many years 
it was thought that the bladder never partook of infection resulting from syphilitic in- 
vasion. Duroux of Paris (quoted bj’ Lowsley and Kerwin) in 1913, gave the first ex- 
tensive review, and collected 26 cases of tertiary vesical syphilis. Karl Pranz Graeff’ 
in his doctor 's thesis, gives perhaps the most comprehensive study of bladder syphilis. 



Pig. 2. — Same as Fig. 1. 97x. 


The consensus of opinion concerning the diagnosis of gumma of the bladder seems to 
be as follows: A history of syphilis; a positive Wassermann reaction; urinary symp- 
toms, chief of which is hematuria ; and a cystoscopic examination. 

Duroux and Levy-Bing” in 1912, made routine cystoscopic examinations of the blad- 
ders of many syphilitic patients, and they say that syphilitic ulcerations of the bladder 
can exist without producing any symptoms referable to the urinary tract. Such was the 
fact in our case — no hematuria or frequency of urination. 

Graeff= says that syphilis of the bladder can exist either as a cystitis, as ulcerations, 
or as gummas, and also makes the statement that gummas can exist a long time without 
giving symptoms. 

Only two articles are available in the American literature, one by M. Morris,’ and 
another by S. W. Schapiro.’ In neither of these cases were there any microscopic re- 
ports ; the diagnosis being based on the history, the cystoscopic findings, the symptoms, 
and the therapeutic test. Sehapiro ’s case also had a positive Wassermann. 


746 


AjMERICAIn journal of obstetrics and gynecology 


Gautier” also reports a case, aud gives a lengthy discussion of the clinical features. 
There are no microscopic reports. 

Alvarez Colodrero" reports two cases wth symptoms like the previous ones, but gives 
no microscopic reports. 


REFERENCES 

(1) Keyes, E. L. : Urology, New York, 1928, Appleton, p. 426. (2) Morton, E. E. : 
Genito-Urinary Diseases and Syphilis, New York, 1924, Physicians & Surgeons Book 
Co. (3) Calot, E. C.: Differential Diagnosis, Vol. 1, Philadelphia, 1916, Saunders. 
(4) Lowsley and Kerwin: Text Book of Urology, Philadelphia, 1926, Lea and Pebiger, 
pp. 33 1. (5) Graeff, Karl F.: Beitrag Sur Kentniss Der Blasensyphilis, etc., 1906. 
(6) n^iro^Kc: Syphilis de la Vessic, These de Paris, 1913. (7) Morris, M.: Indiana 

M. J. 16: 5, 1897. (8) Schapiro, S. W.: Am. J. Surg. 29; 213, 1915. (9) Gautier, 

E, L.: Bull. Soe. franc, d'urol. 6: 291, 1927. (10) Alvares Colodrero, Jorge TV., and 
Ei Leila, Pedro : Semana m4d. 1 : 1380, 1930. 

207 Physicians and Surgeons Building. 


REPORT OP A CASE OF MYOMECTOMY FOR AN INTERSTITIAL 
FIBROID COMPLICATED BY A VERY EARLY PREGNANCY* 

Hiram N. Vineberg, M.D., New York, N. Y. 

A YOUNG woman, aged twenty-eight, married eighteen months, consulted me in No- 
vember, 1929. Briefly her history was as follows: Menstruated at thirteen, four 
weekly type, four to five days ’ duration, moderate in amount and without much pain. 
She had never been pregnant. In June of the same year she was operated upon pre- 
sumably for appendicitis, the surgeon finding onlj’ what was probably a normal appen- 
dix. He lengthened the incision upwards and doivnwards so as to make a thorough ex- 
ploration. This revealed an enlarged uterus, corresponding to the gravid organ at about 
ten weeks, due to an interstitial fibroid. The growth involved the uterus in such a way 
that he deemed anything short of a hysterectomy was at all feasible. Not having ob- 
tained the consent for so radical a procedure, he closed the abdomen after having re- 
moved the appendix. 

The pain in the back from which she had been suffering continued and before seeing 
me, she had consulted a very prominent gynecologist who advised an operation but would 
not give much promise of being able to do anything but a hysterectomy. I found a con- 
dition as above described, the uterus now corresponding to about the twelfth week of 
pregnancy. While unable to give her a definite promise of conserving the uterus, I ex- 
pressed the opinion that I thought a myomectomy could be done and in any case, I 
would make a very determined effort to do so. On January 13, 1930, at Mount Sinai 
Hospital, I opened the abdomen in the median line and delivered the uterus. At first 
sight it did not appear as if a conservative operation could be done. The groivth occu- 
pied the entire anterior wall and it was difficult to discern the fundal part. On close in- 
spection it was made out as a slight projection on the upper posterior surface of the 
growth. The adnexa were normal in appearance, the left one being stretched over the 
growth so that the isthmus seemed to be part of it. My assistants were very positive it 
would not be possible to do a myomectomy. I decided, however, to make the attempt. I 
incised the peritoneum over the lower third of the growth and carried this in a circular 
fashion to the extent found necessary. With the handle of the scalpel and the fingers I 
enucleated it from below upwards. There then remained only the posterior -wall and a 
narrow strip of anterior wall on either side. At the bottom of the wound was a nariow 

‘Read at a meeting of the New York Obstetrical Society, November S, 1932. 



VINEBERG : MYOMECTOMY 


747 


slit extending from the fundus to the internal os. Through this the endometrium pro- 
truded slightlj' and I was struck by its marked purplish color and apparent thick- 
ness. This I attributed to the premenstrual change, the patient having menstruated 
three weeks before (Dee. 20 to 25). I coaptated the edges of the anterior wall ■with 
great care, taking pains to avoid the endometrium. The resulting uterus resembled 
the infantile organ in shape and size excepting it was longer. The patient made an 
afebrile recovery with primary union of the abdominal wound. But she felt poorly, had 
no appetite, was more or less nauseated and felt faint from time to time. On the fourth 
day after the operation there occurred a slight blood discharge, continuing for three or 
four days, which was looked upon as the menstrual period. The patient left the hospital 
January 26, two weeks after the operation. 

On February 11, two weeks later (four weeks after the operation), she came to the 
office and stated that she still felt weak and had had several fainting spells, and that on 
one occasion she passed from the vagina a mass of reddish color and about the size of a 
hen’s egg, evidently a blood clot. March 4 she came again and stated that she had not 
menstruated as yet. She was positive that the time of the last sexual intercourse was on 
January 11, two days prior to the operation and that none had taken place since. I 
found the uterus soft and enlarged to the size of the gravid organ at about eight or nine 
weeks. Thinking there might be a retention of blood, due to constriction of the internal 
os as a result of the operation, I cautiously passed a sound beyond the internal os and 
there being no escape of blood, it da-wned upon me that the patient undoubtedly was 
pregnant at the time of the operation and that she was then probably in the first or sec- 
ond week of gestation. The question then, arose whether or not the pregnancy should 
be allowed to continue. I decided not to interfere, and was upheld in this opinion by 
my colleague and friend Dr. I. C. Kubin. I advised the patient to place herself under 
the service of the Woman’s Hospital for prenatal care and delivery. The pregnancy 
apparently progressed normally. She thought she felt life on April 21. On September 
24 1 found the fundus within a finger ’s -width from the ensif orm and the head low in the 
pelvis. I advised her to seek admission to the hospital at once for induction of labor. 
This advice was followed and she was admitted September 26. Castor oil and quinine 
were given but had no effect. The obstetrician-in-chief telephoned that he deemed a 
cesarean section should be done, as he feared the uterus would rupture when labor pains 
set in. He was kind enough, however, to be guided by my opuiion to the contrary. The 
patient was, therefore, discharged the next day and instructed to return as soon as labor 
pains set in. Until then the movements of the fetus were very marked but apparently 
they ceased a day or two later for she no longer felt them. 

Two weeks later pains set in spontaneously and she was readmitted to the Hospital, 
October 11, where she delivered herself, after a labor of twenty-one hours, of a macer- 
ated fetus weighing 5 pounds, 13 ounces. The puerperium was uneventful. On March 
9, 1932, the patient was delivered again at the Woman’s Hospital at full term of a male 
child, weighing 7% pounds. The labor was moderately difScult, lasting thirteen hours 
and necessitating low forceps. The puerperium was normal. In October I personally 
examined her in my office. The uterus was then of normal size and in proper position. 

The special features of the above case are: 

1. The continuance of the early pregnancy despite the extensive operation on the 
uterus. 

2. The difdculty at the beginning of arriving at the correct diagnosis. 

3. The justification of the assumption that the uterine scar would safely withstand 
the strain of labor. 

The last normal menstruation occurred December 20 to 25. The first coitus after 
this was on the night of December 27, and had been repeated about t-wice a week until 
January 11, i. e., two days prior to the operation. Assuming even, therefore, that con- 
ception had taken place at the first cohabitation, the ovum at the time of the operation 
could not have been older than seventeen days. That it had reached the uterine cavity 



748 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


before that may be safely assumed from the fact that the tubes had been carefully in- 
spected and nothing abnormal noted, excepting that the left one ivas stretched over the 
growth and was very much thinner in consequence, and also fronrthe appearance of the 
exposed endometrium. 

1185 Park Avenue. 


COMPLETE PLACENTAL DETACHMENT WITH APOPLEXY 
OF THE UTERUS REQUIRING HYSTERECTOMY* 

Dr. M. L. Leventhal, Chicago, III. 

T his patient was a primipara, thirty years old, who was admitted to the Michael 
Keese Hospital at 4:45 p.m. on December 4 on the obstetric service of Dr. Lack- 
ner. At 2 p.m., one-half hour after a normal bowel movement, she had severe pain 
in the abdomen associated with dizziness on standing. Her last menstrual period 
had occurred on March 18. No fetal movements were felt following the onset of the 
pain. 

In her past history there were two induced abortions in 1924 and 1927. The patient 
was last seen at the clinic one week before admission at which time her blood pres- 
sure was 110/80, the urine was negative, and she was feeling fine. 

On admission the patient had a blood pressure of 140/90; the urine showed 3-plus 
albumin with a few granular casts; temperature was 99.4°, pulse 76, respiration 22 . 
The color of the skin and mucous membranes was good. The patient felt quite 
well except for some abdominal pain. The red count on admission was 3,750,000 and 
hemoglobin was 75 per cent. Blood chemistry was normal. The uterus %vas the size 
of a full term pregnancy and was in a state of constant contraction. The cervix 
was etfaeed with 2 cm. dilatation. 

Since the patient’s condition was good it was decided to use conservative treat- 
ment. On the following morning, having been quite well during the night, the patient 
began to appear very pale and restless. Pulse was 84, temperature 99.8, red count 
2,170,000 and hemoglobin 50 per cent. The fundus was somewhat hard and of a 
woodj' consistency. Cesarean section was performed at this time with the diagnosis 
of bleeding into the uterus. The abdomen on opening contained about 16 ounces of 
free serous fluid. The uterus was very hard and m.arkedly hemorrhagic and presented 
the appearance of a large twisted ovarian cyst. A low cervical cesarean section was 
performed and a macerated fetus delivered. The uterine cavity was filled with black 
blood clots. The uterine wall was markedly infiltrated ivith blood. Because of the 
marked bleeding and the apparently hopeless condition of the uterus and the con- 
dition of the patient, it was decided to doi a supracervical hysterectomy. The opera- 
tion was followed by an intravenous infusion of 500 c.c. of whole blood. The patient 
left the operating room in good condition. Three days after operation her red count 
was 1,810,000, with a hemoglobin of 50 per cent. Another transfusion of 500 c.c. of 
whole blood was given for the anemia and the patient left the hospital eleven days 
after operation in good condition. 

ABSTRACT OP DISCUSSION 

DR. RUDOLPH W. HOLMES.— I am glad Dr. Leventhal did not say he had a 
case of abruptio placentae because the term has been objectionable to me since I 
coined the term ablatio placentae in 1901. Abruptio implies that the condition has a 
violent, sudden onset which is only true in something like 10 per cent of cases: in 


♦Presented at a meeting of the Chicago Gynecological Society, December 16, 1932. 



LEWNTHAL: PLACENTAL, DETACHMENT 


749 


the remainder the onset may he insidious, or the symptoms so masked that for a 
period one may justifiably be in doubt as to the diagnosis: the literature is replete 
■with records supplied bj' expert obstetricians -wherein this statement is substantiated. 
This implieation carries a gross error just as accidental hemorrhage, originated by 
3iigby, gives the erroneous conclusion that some catastrophe -was responsible for its 
genesis. 

Dr. Leventhal accentuated the fact that he took the blood pressure reading — this is a 
vitalty important observation, especially in instances of uteroplacental apoplexy, in 
spite of the fact that in Preston Willson’s collation of eases, some 67, there -were only 
about a half dozen -where the pressure reading -was recorded ; and of these they ranged 
from normal to over 200 systolic: -we need a cumulative study again to determine the 
true interpretation and value of pressure readings: my o-\vu surmise is that pressure 
readings -will eventually contribute to a dififerentiation of the nontoxie types from 
Couvelaire's toxic apoplexy. 

The next thing I -would stress is the vital necessity of having repeated hemoglobin 
tests -with careful blood counts — not only of the ‘ ' reds ’ ’ but I believe equally important 
it is that the leucocytes should be enumerated. I called attention to this in connection 
with toxic apoplexy in my paper published in 1923, for in my case the uterine and pla- 
cental blood spaces -were teeming with polymorphonuclear leucocytes. 

As regards routine hysterectomy for uteroplacental apoplexy, I believe Whitridge 
Williams erred in maintaining that every ease should be hysterectomized, basing his 
recommendation upon his two personal eases. Certain cases must have the uterus re- 
moved if we would place the woman in the minimum of jeopardy: We must concede 
this question has not been effectively answered. At the present moment I would sur- 
mise that we should perform hysterectomy when the uterus feels like water-soaked 
leather, there is no bleeding from the cut surfaces, and no attempt at contraction even 
after strenuous endeavors to secure muscular action — ^by massage, hot packs, pituitrin, 
ergot. Conversely, if the uterine wall is living, evidenced by contractility and bleeding 
from the cut surfaces, then it may w'isely determine conservation of the uterus. I am 
still firmly con-vinced that ablatio may be the result of some pathologic state foreign to 
toxemia, may be due to an accident, and may be due to a definite toxemia as suggested 
by Couvelaire. Based on my own personal experience from 23 cases of ablatio I would 
decry any attempt to demand that all must be delivered by cesarean section, and I 
would lend my voice in objection to a routine hysterectomy. In my series one only was 
delivered by an abdominal operation, she -W'as the basis of my paper in 1923, and she 
survived. Three died, 13 per cent; one succumbed from the hemorrhage, ante- and post- 
partum hemorrhage : one died in eclampsia some twelve hours postpartum ; the twenty- 
third case entered the hospital -with double ablatio retinae, toxic apoplexy surmised from 
her general condition, a severe cardiovascular break, dying "from the heart” approxi- 
mately forty-eight hours postpartum. How many of these were true instances of tox- 
emic apoplexy is a conjecture, for, as yet, conclusive proof of placental apoplexy only 
is forthcoming from an inspection of the uterus. However, conceding that ablatio in- 
variably is due to toxemia then the fact that 19 of the 22 which were delivered per 
vaginam recovered is proof positive that hysterectomy is not an essential curative detail. 
In Willson’s collection hysterectomy was fatal in 47.6 per cent (21 cases, 10 deaths) 
while in patients in whom the uterus was left but 19 per cent (21 cases, 4 deaths) 
succumbed. 



EEPORT OP A CASE IN WHICH A STEM PESSARY HAD BEEN 
EMBEDDED FOR FIFTEEN YEARS IN THE UTERUS*' 

Prkd L. Adair, M.D., Chicago, III. 

T he uterus from a woman, fifty-one years old, contained a number of small fibroids 
and a stem pessary, which according to the patient's statement, had been in the 
uterus fifteen years. It is a rather peculiarly shaped pessary. She had relatively few 
symptoms except menorrhagia and metrorrhagia for one year. She had one profuse 
hemorrhage lasting forty-eight hours and accompanied by the passage of a good many 
clots. The findings were a somewliat asymmetrically shaped uterus, rather firm and 
hard with multiple fibromyomas, some laceration of the cervix and a foreign body in 
the uterus. "We could feel and hear a metallic click on the passage of a sound into the 
uterus. The pelvic floor was also relaxed. The uterus measured 13 by 9 by 8 cm. with 
the cavity 11 cm. deep. The greatest tldckness of the uterine wall was 4 cm. and the 
endometrium was 1 cm. thick. 

There have been three other cases of this type in the Cliicago Lying-in Hospital. 
One case. Dr. Serbin attended after the patient developed sepsis ; she . died. Non- 
hemolytic streptococci and staphylococci were recovered from the peritoneal fluid. An- 
other ease was of a woman, twenty-one years old, who had a pessary inserted following 
an induced abortion in 1929. Later she developed a rather severe pelvic inflammatory 
condition and was operated upon two and one-half j'ears later at our clinic. There was 
another case in which a pessary had been inserted in the uterus and the women later 
conceived. At the time of delivery the pessary was embedded in the placenta. 

DISCUSSION 

DE. AETHUE H. CUETIS. — Dr. Jones and I had more than a half dozen of these 
pessary cases at St. Luke’s Hospital. In one patient a pessary liad been inserted, and 
fearing she would become pregnant a second one was inserted, forcing the first pessary 
upward and through the fundus of the uterus. We also had a very interesting experi- 
ence many years ago with a patient admitted with a very serious pelvic peritonitis. 
She insisted that she was not pregnant and that nothing had been done in an instru- 
mental way. There were pelvic inflammatory masses, two abscesses almost as large 
as a child's head. She finally recovered and left the hospital. The masses disappeared 
completely. Two years later she returned to the hospital with a recurrence of the 
pelvic perintonitis. She again denied pregnancy or attempted abortion, but finally 
admitted that in order to avoid pregnancy she had had a stem pessary inserted before 
the first attack of pelvic peritonitis and a year and a half after that attack she had a 
second stem inserted with a recurrence of the peritonitis. 

DE. N. S. HEANEY. — I removed the uterus in a case of this sort not suspecting 
the presence of a stem pessary until after the uterus was excised. The patient had 
had depleting hemorrhages over a long period of time, was forty years of age, and 
medical treatment had failed to control the bleeding. She had had the pessary in- 
serted a number of years before and had forgotten all about the incident. We did not 
have an x-ray made in advance. 

DE. O. S. PAVLIK. — At the Northwestern University Dispensary a woman came in 
complaining of severe pain and a foul bloody discharge. On examination we found a 
pessary with a ring, like the one reported by Dr. Adair. The question was whether or 
not we could pull it out or would have to resort to surgery. Finally after some effort 
we pulled it out. Its removal was followed by' a discharge of foul material. 

Some years ago we had a case in which we could see on x-ray examination a foreign 
body resembling the rubber tip of a dropper. On opening the uterus we found a 
pessary that had been there six or seven years. 


Presented at a meeting of the Chicago Gynecological Society, November IS, 1932. 

750 



THE VIABILITY OP FRAGMENTS OP MENSTRUAL 
ENDOMETRIUM 

Samuel H. Geist, M.D., New York, N. Y. 

(From the Gynecological Service, Mount Sinai Hospital) 

I T HAS been sliown that the menstrual blood, escaping from the uterus, contains 
fragments of uterine mucosa. The presence of these fragments has been utilized 
as a means of differentiating menstrual blood from other hemorrhagic vaginal dis- 
charges. 

Prom the morphologic characteristics of the individual cells and from their tinctorial 
reactions, it vras assumed that these cells were viable. Sampson, who has so well de- 
scribed the clinical picture which has been termed endometriosis, has offered as a pos- 
sible explanation the retrograde transportation of menstrual fragments through the 
tube with implantation and growth in the peritoneal cavity. To substantiate this 
theory one must prove that the menstrual fragments can pass through the tube and 
that they are viable. 

While it has been shown bj' Jacobson and others that the transplanted endometrium 
can grow, it has not been demonstrated that fragments desquamated during the men- 
strual period can implant themselves and grow. We were able to prove that the frag- 
ments desquamated during menstruation were small enough to pass through the tubal 
lumen and also that they W’ere composed of living cells. A small amount of the men- 
strual blood collected in a test tube as it escapes through the cervix is drawn through 
a capillary pipette, the lumen which is one-third of that of the interstital portion of 
the normal tube. From this aspirated fluid smears are made and stained supravitally. 
This technic is as follows; 

Stoch Solutions. — (1) Saturated solution of neutral red in 95 per cent absolute al- 
cohol (Pg 7). (2) Saturated solution of Janis green B. in 95 per cent absolute alcohol 
(Ph 7). 

Directions. — A. Mix twelve drops of Solution 1 with forty drops of Solution 2. 
Glass slides must be absolutely clean and neutral in reaction. Cover glass slides with 
fihn of Solution A. When dry place a drop of blood on the slide and cover immediately 
with a cover slip and seal with vaseline. 

The appearance of stained granules, greenish to brownish in color within the cyto- 
plasm of these endometrial cells demonstrates that they are living and remain alive 
for at least one hour after they escape from the cervix. The fact that these fragments 
are living and that they can be aspirated through a pipette whose lumen is only one- 
third of that of the normal tube, demonstrates that the Sampson theory is a possible 
one, in so far as these tiny fragments can pass through the fallopian tube' and be de- 
posited on the peritoneum. 

It is evident also that the desquamation of mucosa is not due to a local necrosis, for 
if this were so, the necrotic fragments would not remain alive. This fact makes it 
necessary to assume some other hypothesis to explain the bleeding of normal menstrua- 
tion. 

. I wish to thank Dr. Nathan Rosenthal, Hematologist to the Mount Sinai Hos- 
pital for his help and suggestions. 

55 East Washington Street. 


751 



PLACENTA PREVIA WITH TWIN PREGNANCY* 

James S. Raudenbush, M.D., Philadelphia, Pa. 

O N APEIL 2, 1932, 1 was called to see Mrs. C. S., forty years, para viii. Being ap- 
parently overdue, having slight painless bleeding for over two weeks and now a 
few stray pains, she was sent to the Northeastern Hospital. The suspicion of placenta 
pre’Jia (“marginal” type) was verified and a high classic cesarean section performed. 
The placenta was attached to the front and right of the uterine wall. A strong, active, 
and crying girl was extracted by the feet. Another sac was discovered and its pla- 
centa was low on the left and posterior surface and “marginally” separated, and from 
this was removed, feet first, a cold, quiet, and anemic boy. Both were cephalic presen- 
tations. On account of her age, pelvic conditions, insanitary environments, and eco- 
nomic conditions, I sterilized her and removed the right tube and ovary (laboratory: 
“chronic salpingitis and oophoritis with fibrosis and cystic degeneration of the 
ovary”), Venaclysis during operation, hypodermoclysis afterwards, but she never 
consented to a blood transfusion. No postoperative vomiting nor distention, wound 
healed perfectly, recovery was uneventful. Twenty cubic centimeters of blood was in- 
jected into the boy ’s buttocks and a month later his blood showed, hemoglobin 75 per 
cent, erythrocytes 4,420,000 and leucocytes 8,400. All three recovered. 

The case I am reporting is my first placenta previa complicated by a twin preg- 
nancy, and I have been able to find only one such instance where a cesarean section was 
done, viz.: by Jardine of Glasgow in 1908. All other reported cases were delivered 
by the vaginal route by various methods. 


GAUZE PAD REMOVED FROM THE ABDOMEN! 

Carey Culbertson, M.D., Chicago, III. 

T his specimen (Fig. 1) was removed from a colored patient, aged thirty-seven 
years. She had been operated upon in Arkansas in 1922 for what was said to be 
pus tubes. At that time the appendix was also removed. In 1923 the same doctor op- 
erated upon her again for adhesions. Since that time she continued to have pain in 
the lower abdomen. At times she had more than the usual pains, and there was evi- 
dence of partial intestinal obstruction. In 1927 the patient went to a hospital in 
Chicago and was operated upon for fecal impaction. After this operation she con- 
tinued to have pain in the lower abdomen. Another operation was advised at the 
same hospital but the patient refused. 

She came to me in May of this year complaining of pain in the lower abdomen 
which was intermittent. She had a temperature of 100° on May 9; on the eleventh 
of May she had no fever. I did not operate until June 7. 

Examination of this patient showed her to be well nourished, rather robust. There 
was a mass in the abdomen about 15 cm. above the symphysis and there was some 
tympany present. There was moderate resistance over this mass which was not so 
hard as a fibroid and appeared to be inflammatory. On vaginal examination we had 
the impression that the uterus was involved. The patient had never been pregnant. 
The cervix was normal. 

On May 21 the white blood cell count was 10,400; urine normal. She had two 
median scars in the midline which showed rather diffuse herniation, and one through 
the right rectus muscle. 

When I began opening the abdomen I found the ileum adherent to the subcutaneous 
fat. Dissection was not easy but the bowel was finally freed. Beneath the mass in 

‘Read at a meeting of the Obstetrical Society of Philadelphia, November 3, 1932. 
tPresented to the Chicago Gynecological Society, June 17, 1932. 

752 



ALLEN: ABDOMINAL PREGNANCY 


753 


the lower abdomen there -was a uterus containing two rather small fibroids. There 
was no right appendage. The cecum was fixed between the uterus and the right pel- 
vic wall and apparently in good condition. On the left side there was a cystic ovary 
about 9 cm. in diameter with a tube that was thickened. This was all adherent and 
could not be delivered without rupturing. A subtotal hysterectomy and enucleation 
of the left appendage was done. The loops of the ileum were freed from the adhe- 
sions which were gossamer-like, fine and delicate. In removing the ileum from the 
right abdominal wall I detected the odor of escaping intestinal material and found a 
tiny hole in one of the loops of ileum, which was repaired by a purse-string suture. 
The operation being completed, apparently, I put my hand into the upper abdomen and 
felt a mass which seemed to be rather free. It was very hard, irregular, suggesting a 
malignancy of the bowel. I enlarged the incision upwards and pulled this mass down. 
It proved to be a dilated portion of the small bowel, distended to a diameter of 8 cm., 
and had a liard mass in it. Tlie omentum was above it and free. Because the lumen 
of the bowel was distended, I made an incision and was able to extract from it this 



Pig. 1. 


specimen which proved to be a piece of gauze. The incision in the bowel was repaired 
and the abdomen closed, with a cigarette drain inserted through a stab wound made 
toward the right. 

The patient has made a satisfactory recovery without any distention whatever. 

This piece of gauze apparently represents an ordinary laparotomy pack, and it was 
free in the lumen of the bowel. The distended bowel wall was somewhat thickened, 
but no changes were observed in the mucosa. 

185 North Wabash Avenue. 


ABDOMINAL PREGNANCY COMPLICATED BY ECLAMPSIA* 
Edward Aiaen, M.D., Chicago, III. 

A COLORED primipara, aged twenty-one, was admitted to the Central Free Dis- 
pensary Nov. 11, 1928. Last menstrual period occurred on May 7, 1928. At 
that time nothing unusual was found on examination by the attending physician ex- 
cept a strongly positive Wassermann, and she was referred to the Dermatological 
Bepartment for treatment. The blood pressure at this examination was 110/60 and 
the urine clear. 

The externe was called to see the patient in her home on account of pains in the 
abdomen on Deo. 2, 1928. He referred her to the hospital for further examination as 

“Presentea at a meeting of the Chicago Gynecological Society, June 17, 1932. 



754 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


a suspect abdominal pregnancy. This was confirmed by x-ray and vaginal examina- 
tion. The period of gestation was estimated at just short of seven months. . It was 
decided to keep her under close observation until the fetus was definitely viable and 
then deliver her by abdominal section. 

On December 4 a notation was made that the nurse who called to see her was un- 
able to obtain a specimen of urine. However, on December 8 one was obtained which 
was normal and the blood pressure stood at 118/60. 

In the afternoon of December 24 the husband called and said his wife had had a 
fit. She was transferred immediate!}' to the hospital. When we saw her one hour 
later she had had a second convulsion and was in the midst of a third typical eclamptic 
seizure. The systolic pressure at this time was 154 and the urine contained 3 mm. of 
albumin. The heart tones were 142, regular, and heard best in the midliue about 
three fingerbreadths above the navel. 

She was prepared at once for laparotomy and the abdomen opened by midline 
incision. There was an immediate escape of a large amount of amniotic fluid con- 
taining large pieces of fibrin. The membranes were in shreds so that the fetus could 
plainly be seen lying in transverse position just beneath the diaphragm with the head 
directed to the left side of the mother. The infant cried lustily and spontaneously. 
Birth weight 4 pounds 4 ounces. It lived eight hours after delivery. 

The placenta was attached to the left tubal fimbria and bowel. The cord surface 
presented immediately beneath the laparotomy opening. Gentle efforts at explora- 
tion caused some bleeding, so they were stopped, tlie cord cut close and the abdomen 
closed in the usual manner, leaving the placenta in place. 

The patient was given 500 c.c. of glucose and normal salt intravenously before she 
left the operating table. She rested quietly for two hours when another typical con- 
vulsion occurred. This was followed one hour later by still another. Morphine sul- 
phate, grain one-fourth had been given hypodermically following the first postpartum 
convulsion. 

The temperature varied between normal and 100.8° until the sixth day following 
operation. At this time it rose to 101.4° and remained elevated between 100 and 
104 the remaining twenty-six days that the patient was in the hospital. During the 
pyrexia the patient developed a severe psychosis which the Neurological Service 
seemed to think was on a toxic basis. The patient was transferred to the Elgin Hos- 
pital for the insane. Three weeks after admittance the upper end of the abdominal 
incision opened slightly and a large amount of material identified as necrotic placenta 
by microscopic examination was discharged. The temperature dropped to normal 
rapidly and she was dismissed as cured ten days later. 

Vaginal examination three months later revealed a normal pelvis with the uterus 
freely movable and menstruating normally. Blood pressure at this time was 112/68. 
The urine was normal and the Wassermann negative. 

55 East Washington Street 



A SPECULUM FOE USB IN CEEVICAL CAUTEEIZATION^^ 

Edward Francis McLaughlin, M.D., Philadelphia, Pa. 

T he primary function of a vaginal speculum is to give proper exposure of the parts. 

In cauterization work a second tiling is desirable, protection. In developing this 
speculum, I tried to combine the two essentials. The instrument is in effect a two- 
bladed speculum Avitli side walls on each blade. The upper blade in cross-section looks 
like an inverted “U” and fits into the upright “U” of the lower blade when closed. 
Two sizes have been made. The larger one has a spread of 2% inches at its end, with 
no space between upper and low’er blades, the smaller about 1% inches. 

Insertion of the larger speculum is accomplished by depressing the perineum with 
the index and middle fingers separated, and then directly inserting the instrument. 



Eig. 1. — A. new vaginal speculum for cauterization treatment of the cervix. 


Wlien inserted the cervix can be brought into view and adjusted into position as with 
a Graves’ speculum. This cannot be done as well with a tubular speculum. In with- 
drawing a gentle rotary movement is made as the blades are allowed to collapse and the 
speculum removed. 

The larger speculum has been used in nulliparous marital vaginas without discom- 
fort, but is moat applicable to multiparous ones. The smaller type is inserted sidewise 
as is an ordinary Graves ’ speculum and withdrawn as is the larger one. It is applicable 
m those eases where the larger one is unsuitable. 

It may be used: 

1- In multiparae where the relaxed vaginal walls ‘ ‘ fold in ’ ’ between the blades of 
Ordinary specula. 

2. In nulliparous patients where the use of a speculum is a new experience and where 
a burn would prove greatly annoying. 

3- In nervous and mentally deficient persons where sudden movements on the table 
Slight cause burning. 

■jjjjg^i'osented at a meeting of the Obstetrical Society of Philadelphia, October 6, 

7.5a 


756 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


4. In teaching cauterization to students where a slip of the hand would ordinarily 
mean a burn. 

5. Another use has been suggested and is being tried with some additions to the 
present speculum, namely, direct x-ray treatment to malignant cervices. 

4116 North Broad Street. 


ASPERGILLUS PUIMIGATUS VAGINITIS* 

LIark T. Goldstine, M.D., Chicago, III. 

A EEVIEW of the literature on leucorrhea secondar}' to Aspergillus fumigatus 
shows no reported cases. 

This patient presented herself for examination December, 1931. She was thirty- 
nine years old, married eighteen years, sterile, with negative menstrual history. Her 
health had been good. The present complaint was nonirritating, odorless leucorrhea 
of several years’ duration, and an intermittent pruritis vnlvae. 



Pelvic examination revealed a slightly red and irritated vulva with a grayish dis- 
charge which was also present in the vagina. This discharge was microscopically nega- 
tive. On the posterior vaginal wall and the posterior cervical fornix were numerous 
grayish white nodules about 2 to 4 mm. in diameter. Tliese were firmly adherent and 
on removal left a raw surface. Histologic examination of four of these small nodules 
revealed the presence of a fungus growth readily identified as Aspergillus fumigatus 
growing in necrotic tissue. 

25 East Washington Street. 


•Presented at a meeting of the Chicago Gynecological Society, June 17, 1932. 



Society Transactions 


NEW YOEIC OBSTETRICAL SOCIETY 

STATED MEETING, OGTOBEE 11, 193S 

Injuries to the Vagina Kesulting From the Elliott Treatment. De. Samuel A. 
CosGKOVB AND Dr. Edwaed G. Watees, Jeesey Gity, N. J. (For original article see 
page 729.) 

Some End Results of 1,114 Cases of Prolonged Labor at the Manhattan Maternity 
and Dispensary. Dr. Egbert Lq-weie. 

Diabetes and Pregnancy. Dr. J. Eonsheim, Brooklyn, N. Y. (For original 
article see page 710.) 


NEW YORK OBSTETRICAL SOCIETY 

MEETING OF NOVEMBER 8, 1938 
The following papers were presented : 

Report of a Case of Myomectomy for an Interstitial Fibroid Complicated by a 
Very Early Pregnancy. Dr. H. IST. Vineberg. (See page 746.) 

An Experimental Study of the Effects of Intravenous Injections of Hypertonic 
Glucose Solution (50 per cent) on the Circulation of the Cat. Dr. V. P. Mazzola 
and Marcus A. Torrby. (See page 643.) 

Conization of the Uterine Cervix. Dr. M. N. Hyams. (See page 653.) 


NEW YORK OBSTETRICAL SOCIETY 

MEETING OF DECEMBER 13, 1938 
The following papers were presented : 

A Clinical Study of Avertin in Gynecology and Obstetrics. Dr. G. Gordon Bemis. 
(By invitation.) (See page 677.) 

The Mechanism and Management of the Third Stage of Labor. Dr. M. L. Brandt. 
(See page 662.) 

Injury to the Urinary Bladder Following Irradiation of the Uterus. Dr. A. L. 
Dean, Jr. (By invitation.) (See page 667.) 


OBSTETRICAL SOCIETY OF PHILADELPHIA 

MEETING OF OCTOBER 6, 1938 
The following papers were presented: 

A Speculum for Use in Cervical Cauterization. Dr. E. F. McLaughlin. (See page 
755.) 

Hyperthyroidism Associated With Pregnancy. Dr. F. A. Bothe. (See page 628.) 

Concerning Death of the Fetus in Pregnancy. Dr. J. S. Lawrance. (See page 
633.) 

Observations Upon Adynamic Ileus. Drs. E. A. Schumann and J. V. Missett. 
(To be published in a subsequent issue.) 



758 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 

OBSTETEICAL SOCIETY OP PHILADELPHIA 

MEETING OF NOFEMBEF 3, 1932 
The following papers were presented: 

Placenta Previa With Twin Pregnancy. Dr. J. S. Raudenbush. (See page 752.) 

Dbderlein’s Bacillus in the Treatment of Vaginitis. Drs. E. W. Mohler and C. P. 
Brown. (See page 718.) 

Primary Carcinoma of Bartholin’s Gland. Dr. W. B. Haeer. (See page 714.) 

Pelvic Sympathectomy for Pain in Carcinoma of the Cervix. Dr. C. A. Behney. 
(See page 687.) 

Aschheim-Zondek Pregnancy Test, Friedman Modification. Drs. B. Mann, D. 
Meranze, and L. Golub. (See page 723.) 


CHICAGO GYNECOLOGICAL SOCIETY 

MEETING OF JUNE 17, 1933 
The following case reports and papers were presented: 

Abdominal Pregnancy Complicated hy Eclampsia. Dr. E. Allen. (See page 753.) 

Gauze Pad Removed From the Abdomen. Dr. C. Culbertson. (See page 752.) 

Aspergillus Fumigatus Vaginitis. Dr. M. T. Goldstine. (See page 756.) 

The Irregularity of the Menstrual Function. Dr. E. Allen. (See page 705.) 

The Volumetric Determination of Anmiotic Fluid With Congo Bed. Dr, W. J. 
Dieckmann and Dr. M. E. Davis. (See page 623.) 

Hydrocephalus and Cyclocephalus. Dr. W. B. Serbin. (Abstract follows.) 

Mrs, E. E., aged thirty -five, gravida one, was admitted to Wesley Hospital in labor 
on February 22, 1932, apparently at term. After approximately seventy-two hours 
the cervix was not more than 8 cm. dilated, although completely effaced. Because of 
irregular fetal heart tones and maternal exhaustion, immediate delivery was decided 
upon. Two Diihrssen ’s incisions, each about 2 cm. long, were made and cervical dila- 
tation was artificially completed. The head was in occiput left transverse position and 
its lowest portion was 1 cm. below the ischial spines. It was manually rotated through 
an arc of 45° and the forceps applied as in occiput left anterior. With a single trial 
traction the forceps slipped and it was immediately decided that the case was not one 
for forceps extraction. Further careful examination revealed large anterior and pos- 
terior f ontanelles and widely separated sutures ; the left ear could not be palpated. A 
diagnosis of hydrocephalus was made and delivery completed by craniotomy and 
cleidotomy. In addition to the hydrocephalus the baby was a cyclops monster, sub- 
variety cyclocephalus with rudimentary eye and central single eyelid upper and lower ; 
cleft upper lip in midline (not a true harelip) ; partial cleft palate ; bilateral pes varus ; 
hypoplasia of left auricula and absence of left external acoustic meatus; absence of 
external nose; aplasia of cerebrum, the latter being represented by two soft fibrous 
masses; absence of cribriform plate of ethmoid; absence of olfactory lobe and olfac- 
tory nerves ; single apparently fibrous nerve branching off from optic chiasma ; absence 
of oculomotor nerve; hypoplasia of hypophysis, thyroid and adrenal glands. 

Tlijanus, heart, lungs, gastrointestinal tract and urogenital organs present and ap- 
parently normal. 

Microscopically, liver well marked; myelopoietic tissue around larger blood vessels; 



SOCIETY TRANSACTIONS 


759 


nvunerous small foci of erytliTopoiesis ia liver sinusoids; distinct evidence of retarded 
development. Thyroid fibrotic; increase in fibrous tissue. Stroma, some colloid in a 
number of acini. Lung: aeration incomplete; myeloid foci about some of the larger 
blood vessels; retarded development. Pancreas: fat and fibrous tissue; lobules sur- 
rounded by fibrous tissue stroma. Adrenal: medulla normal, cortex underdeveloped. 
Thymus and spleen normal. 


CHICAGO GYNECOLOGICAL SOCIETY 

MEETING OF NOVEMBEB 18, 1932 
The following papers were read: 

Report of a Case in Which a Stem Pessary Had Been Embedded for Pifteen Years 
in the Uterus. De. Fred L. Adair. (See page 750.) 

Report of a Case of Teratoma of the Uterus With Fetal Implantation. Dr. J. E. 
Lackner akd Dr. L. Krohn. (See page 735.) 

Psychogenic Factors in Functional Female Disorders. Dr. K. Horney. (See 
page 694.) 


CHICAGO GYNECOLOGICAL SOCIETY 

MEETING OF DECEMBER 16, 1932 

The following papers were presented: 

Complete Placental Detachment With Apoplexy of the Uterus Requiring Hyster- 
ectomy. De. M. L. Leventhal. (See page 748.) 

Tubal Pregnancy Following Uterine Insemination. De. E. A. Lifvendahl. (See 
page 733.) 

The Relation of Season and Constitutional Type to Menstruation. Dr. L. Arnold. 
(Abstract follows.) 

The amount of material lost during menstruation, the duration of menses in 
hours, were accurately determined upon 317 normal women in a large factory over 
a period of two years. There was a shortening of the intermenstrual period during 
March (spring season) and also during September (fall season). The average dura- 
tion of menstruation was found to be sixty-five hours. The average loss for this 
group was 43.4 gm. The seasonal changes in the time, duration, and amount of mate- 
rial lost in grams were illustrated by graphs and charts. The duration in hours of 
the menses was shorter during the warm months of the year. The amount of material 
lost in grams was not altered. The grams lost per hour of menstruation was there- 
fore greater during the summer than during the winter months. The work is being 
continued, hemoglobin determinations are being made and bacteriologie studies of 
used pads are being carried out. 

Biochemical Alterations and Their Relations to the Menstrual Cycle. De. W. F. 
Petersen. (Abstract follows.) 

In a studj’ of the normal female by means of daily blood chemical and clinical 
examinations over long periods of time, the rhythmic alterations due to endocrine 
and seasonal effects were studied. The influence of alterations of the general chemi- 
cal status v-ith the menstrual period and its influence on the effect of sex hormones 
and on the rliythmic character of the menstrual flow were likewise observed. 



Department of Reviews and Abstracts 

Conducted by Hugo Ehrenfest, M.D., Associate Editor 


Collective Review 


ACUTE (EXTRAGENITAL) INFECTIONS IN PREGNANCY, 
LABOR, AND THE PUERPERIUM^' 

J. P. Greenhill, M.D., Chicago, III. 

A cute infections 'whicli complicate pregnancy, labor and the puerperium usually 
have more evil consequences than when they occur in nonpregnant individuals. 
Both maternal and fetal mortality are usually high. Part of the increased ma- 
ternal death rate is attributable to the stress and strain of abortion or labor which often 
decrease the patient’s resistance considerably. This is certainly true when the lungs 
are involved. Furthermore, some diseases lead directly to puerperal sepsis. 

In most acute infections, labor pains are not disturbed and tlie third stage of labor 
is usually normal. Occasionally postpartum hemorrhage occurs. The puerperium in 
most cases is not unusual. Only when the specific organism stimulates the pyogenic 
bacteria in the genital tract so tliat secondary infections occur, is there increased 
susceptibility to puerperal complications. Involution usually progresses normally. 

Not only may tlie acute infections disturb pregnancy, labor, and the puerperium 
but the reverse also holds true. Many infections run a much more serious course dur- 
ing pregnancy tlian otherwise, and the gravitj' is usually increased when pregnancj' 
is interrupted as a result of the infection. The increase in mortality and morbidity is 
due to the sudden change in metabolism, the blood loss and exhaustion which occur 
during labor. Since interruption of gestation does not help but in most cases makes 
matters distinctly worse, artificial interruption of pregnancy is contraindicated. 

In a large proportion of cases, abortion occurs. Many authorities believe that the 
high fever which is associated with acute infections is responsible for the large number 
of abortions. Eunge showed that among rabbits, the fetuses die in utero if the mothers 
are subjected to high temperatures. He also proved that heat stimuli when applied 
to the uterus of a rabbit produced tetanic contractions of that organ. Eunge concluded 
that while heat was not the sole cause of fetal death, it was an important factor. 
Hence, it is necessary to reduce the high temperature in pregnant women. Seitz on the 
other hand, does not believe that fever is a cause of fetal death. He considers the 
toxemia produced by the bacteria as the important etiologic factor, because these 
toxins, like other protein products, stimulate uterine activity. Seitz is of the opinion 
that both the fever and the uterine contractions are due to bacterial toxins. In pneu- 
monia additional factors stimulate the uterus to contract, namely the lack of oxygen 
and the excess of carbon dioxide. 

In some instances pathologic changes in the placenta are responsible for the inter- 
ruption of gestation. These changes are due to bacteria or toxins in the maternal 
blood. In many cases the living or dead fetus does not show any changes which indicate 
the transfer of the disease from mother to offspring. In others, however, the placental 
barrier is not so effective and bacteria gain access to the fetus. 

An important question is the transfer of immunity from the mother to the fetus. 
Ehrlich proved experimentally in mice that immunity in the father is not transmitted 
to the fetus; but immunity induced in the mother before pregnancy supervened is 

’Orig-inallj'' prepared for the Committee on Factors and Causes of Fetal, Newly- 
Born, and Maternal Morbidity and Mortality of the White House Conference on 
Child Health and Protection. 

760 



REVIEWS AND ABSTRACTS 


761 


transmitted to tlie fetus. This immunity persists for about three months. The short 
duration indicates that the immunity is not an active but a passive one and is due to 
the transfer of antibodies from the maternal to the fetal organism. Hence neither 
sperm nor ova can transmit acquired immunity. The temporary immunity is trans- 
mitted first through the placenta at the time of labor and after that through the 
maternal milk. 

In human beings, Pfaundler found that immune bodies may be transferred through 
the placenta, regardless of whether the placenta is intact or not. However, this mode 
of transmission is unusual and not physiologic. The transfer of immune bodies through 
human milk has also been proved but this route is too inconstant to be useful for the 
prophylaxis and treatment of infections. 

Infections which begin during the puerperium are generally not more serious than 
in nonpregnant individuals. The question of nursing is important when an infection 
is present. In certain diseases it is permissible to allow the baby to nurse but in 
others it is dangerous for the child or the mother or both. Where the child has a high 
resistance against an infection as in measles and scarlet fever, nursing may be per- 
mitted. However, where the infant has a low resistance as in typhoid it should be 
separated from its mother as soon as possible. Sometimes the serious condition of 
the mother prohibits nursing regardless of the susceptibility of the child. 

INFLUENZA 

Pregnant women seem to have a distinct predisposition to grippe because this dis- 
ease especially attacks young healthy individuals. The chief characteristic of the 
epidemic in 1918 was severe pulmonary complications especially pneumonia. The lat- 
ter occurred particularly in pregnant women, and it progressed rapidly due to the 
physiologic hyperventilation which takes place during gestation, even in the early 
months. (Hyperventilation which is normally associated with pregnancy is the result 
of the normal acidosis of pregnancy.) 

If a pregnant woman develops pneumonia during an attack of infiuenza, the danger 
is greatly increased should labor set in. The reasons for this are the unfavorable effects 
of strong respiratory movements and the changes in intrathoracic pressure which are 
always present during the second stage of labor. Absolute rest which is essential in 
pneumonia is not obtainable during labor. Furthermore after labor is over, the intra- 
abdominal pressure suddenly decreases and the diaphragm descends. This causes the 
lower portions of the lungs to increase their activity, and they may aspirate inflamma- 
tory products from diseased portions of the lungs. Likewise unavoidable changes in 
the circulatory apparatus during labor have a bad effect on pneumonia. 

Harris by means of a questionnaire obtained information concerning 1,350 cases 
of influenza among pregnant women during the 1918 epidemic. About one-half of all 
the patients developed pneumonia and of these about 50 per cent died, giving a gross 
mortality of 27 per cent. The susceptibility to pneumonia was about the same for 
each month of pregnancy but the mortality was higher (60 per cent) during the last 
three months. Bland found a death rate of 49 per cent for his series. Ottow reported 
a mortality of 55 per cent for pregnant women with influenza as contrasted with 4.5 per 
cent for nonpregnant individuals. Schmitz obtained the following interesting informa- 
tion : The mortality among men was 23.5 per cent, among nonpregnant women it was 
12.5 per cent, and among pregnant woman it was 45.9 per cent. The latter author 
found a mortality of 43.9 per cent for all cases of influenza occurring among pregnant 
women reported by six German investigators. Litwak reported a series of 61 cases of 
grippe observed during an epidemic in Leningrad in 1927 and 1928 but only two 
women died. 

During attacks of influenza in pregnant women the gestation is interrupted spon- 
taneously in about 35 to 60 per cent of all the cases. Most of the interruptions take 
place during the later months, especially near term. When pneumonia complicates 
grippe, the termination of pregnancy is much more frequent than otherwise. Thus in 
Harris’ series, among 626 cases uncomplicated by pneumonia, pregnancy was inter- 
rupted in 26 per cent, where as in the 585 eases complicated by pneumonia, the inci- 
dence was 52 per cent. In 38 per cent of the fatal eases, the patients died without inter- 
ference with pregnancy. In Litwak ’s series of 61 cases only 28 (46 per cent) of the 
pregnancies continued to term. 

When pregnancy is interrnpted the maternal mortality is distinctly higher than 
when the gestation is unmolested. Thus in Harris ’ series among 743 patients in -whom 
pregnancy was not interrupted the mortality was 16 per cent, whereas among 468 
women in whom the uterus emptied its contents, the death rate was 41 per cent. If only 
the pneumonia cases are considered, we find that among 383 cases in which pregnancy 



762 


AMERICAN JOURNAL OP OBSTETRICS AND GTNECOLOGY 


continued there was a mortality of 41 per cent, while among 395 cases in which preg- 
nancy was interrupted the death rate was 63 per cent. 

It was found that in the mild cases of influenza the fetus was not affected hut in 
the severe cases many children died especially during labor. It was not decided whether 
the cause in these eases "was excessive heat due to fever, lack of oxygen due to cyanosis 
of the mother, changes in the circulatory apparatus, or intrauterine infection. Some 
infants died of grippal pneumonia as a result of placental infection probably because 
the decidua is a good focus for puerperal infection. 

Labor is usually rapid in grippe and the uterine contractions are not painful. There 
are generally no disturbances in the third stage but bleeding may occur in the puer- 
perium. _ During the delivery it is hazardous to use a general anesthetic, hence local 
anesthesia should be employed when narcosis is necessary. 

After labor any pulmonary complication which may be present becomes worse so 
that the mortality among these patients is very high during the first few days post- 
pai-tum. If, however, grippe sets in for the first time during the puerperium, the re- 
sults are no worse than for nonpregnant women. 

It is remarkable that puerperal sepsis is not common after influenza because the 
latter is frequently associated with streptococcal infections. However, a few cases 
of sepsis have been reported. If grippe begins in the puerperium it may be difiicult 
to differentiate it from puerperal sepsis but in favor of grippe are negative findings in 
the genitalia, the tendencj’ to pulmonary complications, a slow pulse in relation to a 
high temperature, and absence of hyperleucoeytosis. 

The children of patients with grippe are always in great danger. The fetal mor- 
tality varies between 20 and 45 per cent and this is essentially due to the early inter- 
ruption of pregnancy. Infants may show diseases at birth which are grippal in origin 
such as bronchopneumonia, pleurisy, and peritonitis. Abt reported a case of influenza 
in a newborn Infant. 

The treatment of influenza during pregnancy is the same as in nonpregnant indi- 
viduals. Pregnancy should never be interrupted artificially and if there are signs of 
impending abortion, an attempt should be made to prevent this by absolute rest in bed 
and morphine. All patients should be strictly isolated. De Lee found that absolute 
rest in bed, in a warm but well ventilated room was the greatest single factor in pre- 
venting bronchopneumonia from which the majority of women died. The rest in bed 
should be continued for ten days after the temperature becomes normal. 

The mother may nurse her baby if she is not too ill but she should cover her nose and 
mouth while the baby is at the breast. Baer and Eeis found that breast infections 
showed a direct increase in sequence to the waves of influenza, hence special precautions 
should be taken of the nipples and breasts in patients with grippe. However, such 
prophylaxis will prevent only a small number of breast infections because most of them 
are hematogenous in origin. 

PNEUMONIA 

Schmitt found that among 35,000 obstetric cases in Munich, pneumonia occurred 
44 times or 0.13 per cent, hence this complication is infrequent. Jurgensen observed 
that 2.4 per cent of all cases of pneumonia are complicated by pregnancy. The more 
advanced the pregnancy when pneumonia sets in the greater the risk, and the greatest 
danger exists at the time of labor. Termination of labor does not help the pulmonary 
affliction. 

Pregnancy is interrupted spontaneously in about two-thirds of all the patients with 
pneumonia. The further advanced the pregnancy, the more frequently is gestation 
terminated. The most likely cause of fetal death is toxemia, but there probably are 
other factors such as fever and excessive carbon dioxide in the blood. Pneumococci 
can pass through the placenta to the fetus but this does not frequently occur. Many 
children are born alive and remain healthy. 

Labor, the puerperium, and lactation are usually not affected by pneumonia. 

The treatment of pneumonia during pregnancy is the same as for nonpregnant 
women. Labor should not be induced because the prognosis then becomes worse. Vinay 
collected cases which showed a maternal mortality of 68 per cent when pregnancy was 
interrupted and only 15 per cent when it continued undisturbed. If premature labor 
occurs, delivery should be accomplished as quickly as possible. The second stage can 
usually be eliminated by the use of forceps. Local anesthesia should be used when an 
anesthetic is necessary because a general anesthetic nearly always adds to the mother s 

If pneumonia sets in after delivery it may sometimes be difficult to differentiate it 
from metastatic pulmonary disease. 



REVIEWS AND ABSTRACTS 


763 


SCARLET FEVER 

Scarlet fever is rare among pregnant women. Stolz in 1913 could collect only 20 
cases from the literature. Schmidt who reviewed all the scarlet fever cases at the 
Wiener Infektions Spital during the forty years prior to 1925 found 10 additional cases. 
At the Cliicago Lying-in Hospital, among almost 35,000 patients only three cases were 
observed. Devraigne, Baize and Mayer reported six cases which were seen during two 
epidemics of scarlet fever at the Lariboisiere Maternity. One of the cases occurred 
after an abortion and the others after full term labor. Olshausen who reviewed the 
literature, believes the small number of cases observed during gestation is due to 
the immunity of pregnant women against scarlet fever. De Lee knows of many in- 
stances where labor occurred in the same room with children suffering from scarlet 
fever and he has seen no trouble arise from it. 

Pregnancy is frequently interrupted, especially in the stage of eruption and less 
frequently in the desquamation stage. In Schmidt’s ten cases, however, there were 
only three interruptions. In the remaining seven cases the pregnancies and labors were 
normal. 

Puerperal scarlet fever is interesting because it is difdcult to distinguish from the 
scarlatinal form of puerperal sepsis. In favor of scarlatina is the typical skin eruption 
with subsequent desquamation and eosiiiophilia in the blood. Jurgensen and others 
insist that a true epidemic of scarlet fever among puerperal women has never been 
observed. They say the eases so reported were nearly always septic infections with a 
scarlatiniform skin eruption. This opinion is also shared by Stookey and Downs who 
maintain that scarlet fever occurring in the puerperium is puerperal infection with a 
streptococcus whose exotoxin is capable of producing an erythematous eruption. 
Adults are generally protected against true scarlet fever and this applies to pregnant 
women as well. However, many authorities disagree -ivith Jurgensen, Stookey and 
Downs, and believe that true scarlet fever does occur in puerperal patients. In some 
cases there is a very long incubation period but this is due to the tenacity of the scarlet 
fever organism which remains latent during pregnancy and only shows its pathogenicity 
during the puerperium. Posch reports an epidemic of six cases of scarlet fever which 
occurred in the Innsbruck Maternity at the same time there was an epidemic of scarlet 
fever in that city. All of these patients had the virus of the disease in them before 
they entered the clinic and all but one recovered. Posch maintains that scarlet fever 
in the puerperium differs from the usual type seen in adults. There is usually mild, or 
absence of, anginal symptoms, a short incubation period and beginning of exanthem. 
The portal of entry is usually puerperal wounds, and thus the puerperal woman is in 
greater danger than others. DeLavergne and Fruhinsholz agree with Posch that there 
is a strictly puerperal form of scarlet fever. They say that Durand reported a series 
of 140 cases of scarlet fever in which the disease showed itself during pregnancy 6 times, 
immediately after labor in 8, during the first or second day postpartum in 61, on the 
third day in 27, from the fourth to the eighth day in 22, and after the eighth day in 16. 
They also mention the epidemic reported by Theveny where all eleven cases broke out 
between the third and fifth day postpartum. 

In most cases of scarlatina, the puerperium is undisturbed and the lochia normal. 
Aside from mild tenderness of the uterus there are no pathologic changes in the pelvic 
organs. The mortality from puerperal scarlet fever has decreased considerably during 
the last few years. Olshausen reported a mortality of 48 per cent for the cases he col- 
lected in the literature before 1895, while Gocht in 1894 reported a death rate of only 
8.7 per cent and Schmidt, in 1925, found a mortality of 12.2 per cent. 

In many cases the disease is transmitted to the fetus in utero ; but usually the new- 
born is immune and does not contract scarlet fever even if it nurses its mother. 

Pregnant women should not take care of children who have scarlet fever, and they 
should be isolated from such children if possible. If it appears likely that a woman 
in labor has been exposed to scarlatina or that she may have the disease, no vaginal 
examinations or operations should be undertaken unless they are absolutely necessary. 
This is to avoid a possible secondary infection. When an epidemic of scarlet fever ap- 
pears there is an iucrease in the incidence of puerperal fever because both diseases are 
due to the streptococcus. 

The treatment of scarlet fever during pregnancy is the same as for nonpregnant 
women.' 

It is well known that scarlet fever confers immunity against a subsequent attack. 
Adair and Tiber believe that an attack of scarlet fever in childhood confers some im- 
munity upon women so that these women have less tendency to develop that type of 
sepsis which is due to the streptococcus. In a large series of private and charity pa- 
tients, they found that the patients who had had scarlet fever in childhood had a lower 



764 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


incidence of fever in tiie puerperinm than those who did not have this disease previously. 
Furthermore, among the ten fatal eases -with known streptococcus infections, not one 
gave a history of having had. scarlet fever before. Adair and Tiber point out that it is 
possible the streptococcus toxin may afford us an index of the susceptibility of the 
patient to streptococcus infections. It is also likely that the patient’s immunity to 
streptococcus infection could be built up when this seems to be indicated in susceptible 
persons. 

CHOREA 

Chorea gravidarum is rare and, as emphasized by Campbell, it is most likely an acute 
infection like chorea minor, although some believe it is toxemic in origin. "Willson and 
Preece collected 951 choreic pregnancies which occurred in 797 women reported in the 
literature. In more than 50 per cent of the cases, pregnant women with chorea give 
a history of having had a previous attack, more tlian one-third have had rheumatism 
and more than one-fourth have had both diseases previously. However, in spite of what 
some textbooks say, there is no great danger of recurrence during pregnancy in women 
who had the disease in childhood. Chorea is the most frequent acute nervous disease of 
childhood and if the danger of recurrence during pregnancy were great the number of 
cases of chorea gravidarum would be very large. But it is very small. Burr treated 
more than 3,000 cases of chorea in children but only a few of these returned with the 
disease when pregnant. 

The disease occurs most frequently in primiparas, especially young ones, and it 
may or may not recur in subsequent pregnancies. 

Chorea in pregnancy is serious because the mortality varies from 6 to 36 per cent. 
However, "Vignes maintains that it is not a grave disease because in the 53 cases ob- 
served among the 38,000 deliveries at the Baudeloque Clinic, there was only one death. 
He mentions that in all the hospitals of Copenhagen during a ten-year period, there 
were 41 cases with only one death, one therapeutic abortion and one spontaneous 
abortion. 

The mortality for the patients who have had chorea in childhood is less than one-half 
of -what it is for those who did not have the illness, but the prognosis is especially bad 
for those who have recurrences of the disease in repeated pregnancies. Deaths are 
usually due to muscle spasms of the throat, tongue, and larynx followed by exhaustion, 
aspiration pneumonia, cardiac decompensation, psychosis, etc. Bacchaus says the 
disease is least serious for a child, more for a man, still more for a woman and most 
serious for a pregnant woman. 

The fetal mortalitj' varies from 50 to 70 per cent and many of the children born 
alive are abnormal. The chief danger to the child as far as heredity is concerned is 
an increased susceptibility to rheumatism which may cause chorea. 

Most authorities agree that interruption of pregnancy or spontaneous labor cures 
the disease, hence they advocate evacuating the uterus if the patient’s condition be- 
comes worse in spite of conservative treatment. In some instances, however, the condi- 
tion becomes aggravated after labor. According to Spiegelberg only half of the preg- 
nancies go to term. 

The prophylaxis of chorea consists of proper prenatal care. The essentials are 
sufficient rest, isolation, proper elimination, exercise without fatigue and freedom from 
worry, removal of all foci of infection and special attention to neurotic patients. 

The treatment of chorea during pregnancy does not differ much from the usual 
treatment of this disease. Bed rest and sedatives are essential. If the patient’s con- 
dition progressively becomes worse, it is best to empty the uterus. At or near term it 
may be advisable to perform a cesarean section in primiparas but in most instances 
simple induction of labor is preferable. Eoyston is of the opinion that the interests of 
the patient are best conserved by early emptying of the uterus as soon as a definite 
diagnosis of chorea is made. Since anesthetics are badly tolerated, local anesthesia 
should be used whenever possible. The obstetrician should always call a neurologist 
in consultation in these cases. 

DIPHTHEEIA 

Diphtheria of the throat is rare among pregnant women just as it is very uncom- 
mon among adults in general. (Steen, Casavecchia, Ranson, Hirsch, etc.) However, 
when diphtheria does occur among women who are pregnant, abortion occurs in about 
one-third of the cases. This is due either to the toxemia produced by the disease or 
to respiratory disturbances which result from the laryngotracheitis. 

Diphtheria of the genitalia among pregnant women is likewise rare and it is also 
very uncommon during the puerperium. According to Sigwart during a period of 
thirty years there were only 9 authentic cases of diphtheritic infection of puerperal 



REVIEWS AND ABSTRACTS 


765 


■wounds reported in the German literature. In Prance, Bourut could collect only 43 
cases but 33 of these occurred during one epidemic. 

The first symptoms usually appear three to four days after infection. Most cases 
arise in homes and not in hospitals. The infection usually is contracted from some in- 
dividual who has been in contact with the disease and not because the patient has 
diphtheria bacilli in her vagina, as some maintain. The diphtheritic inflammation has 
a tendency to spread on the surface and not in the depth. When during the course of 
diphtheria, there is involvement of the parametrium and peritoneum this is usually due 
to an associated streptococcus infection. Even when the diphtheritic infection exists 
alone and the local signs and symptoms are mild, the general condition is usually serious 
because of the concomitant toxemia. When there is an associated streptococcus infec- 
tion, the outlook is grave. 

Puerperal diphtheria runs exactly the same course as diphtheria in general. Under 
the influence of specific therapy the membrane is expelled in a few days and a cleansing 
process talves place. The end-results are bad when the disease has existed for a long 
time and serum has been given very late in the course of the disease. Naturally in 
cases of primary diphtheria of the genitalia, other organs may later become involved. 
Thus Bumm described a case of secondary laryngeal diphtheria, and Gourfein one of 
secondary diphtheria of the eye. 

During the last few years much has been written concerning the occurrence of diph- 
theria bacilli in the nose of a large proportion of newborn children. Many outbreaks 
of nasal diphtheria among newborn have been reported, but the disease in these chil- 
dren was usually very mild. The general condition of the babies was usually good but 
frequently otitis media occurred as a complication. The outbreaks of this type were 
generally observed in Europe during epidemics of the grippe, especially during and 
for a few years after the war, Karlbaum, in 1919, reported such an epidemic in the 
Kiel clinic. Of 35 children who had nasal diphtheria 14 died. However, 24 of all 
the children had both nasal diphtheria and grippe. Twelve of the latter group of 24 
died whereas there were only 2 deaths among the 11 children who did not have grippe. 

Subsequent systematic examinations revealed the fact that the number of newborn 
babies in hospitals who had nasal diphtheria formed only a small proportion of the 
number of infants who harbored diphtheria bacilli in their noses. The latter children 
showed no bad effects but were bacillus carriers. This striking finding and also the 
haimlessness of diphtheria in the nervborn is explained by the fact that 84 per cent 
of newborn show immunity against diphtheria toxin as determined by the Schick intra- 
cutaneous test. According to Schick this immunity is rapidly lost so that at the end of 
the first year only 30 per cent show this immunity. More breast-fed babies retain this 
immunity than bottle-fed children. This speaks for the transmission of immune bodies 
through mother ’s milk by means of which the infant can protect itself against a diph- 
theritic infection. 

More uncommon than nasal diphtheria is diphtheria of the umbilicus in the newborn. 
Most of the infections appear at the end of the first week or during the second week. 
Some run a mild course whereas others are serious. 

The source of diphtheria infections is usually difficult to find but in most cases car- 
riers are responsible. Some authors maintain that diphtheria bacilli may be found in 
the vagina of healthy, pregnant and puerperal women. Others believe these bacteria are 
not true diphtheria but pseudodiphtheria bacilli. 

In spite of the relative harmlessness of diphtheria in the newborn, it must be treated 
intensively. First of all serum in doses of 1,000-2,000 antitoxin units should be given 
and all infected children and carriers must be isolated. The attendants should all be 
examined to determine whether they are carriers, and all visitors should be excluded. 
There is no necessity to give serum prophylactically to healthy children in the same 
hospital or home. Attempts have been made to increase the immunity of newborn 
children by the administration of toxin-antitoxin but these attempts have been un- 
successful in spite of the fact that the amount of antitoxin in the cord blood can be 
mcroased fourfold bj^ this means. Local antiseptic treatment is usually unnecessary. 

There is no authentic case on record of the intrauterine transmission of diphtheria 
from the mother to the child. Some authorities advise the immediate separation of the 
newborn baby from its mother 'whereas others permit nursing at the breast. In the lat- 
ter instance the mother should wear a large mask which covers both her nose and mouth. 
Sterile sheets or towels should be placed around the baby while it is with the mother. 

ERYSIPELAS 

Erysipelas during pregnancy is rare but if it occurs, pregnancy is interrupted in a 
certain proportion of cases. When the disease remains localized, the gestation proceeds 



766 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


unmolested, but when there is a generalized infection, the uterus empties itself as a 
rule. It is exceptional to find an infection of the fetus by way of the placenta for Stolz 
could find only six such cases in the literature. During delivery the child may de- 
velop an erysipelas infection of the umbilicus. There was one such case at the Chicago 
Lying-in Hospital but not a single instance of erysipelas in any of the 35,000 mothers. 

Even before our knowledge of the existence of bacteria, it was recognized that puer- 
peral sepsis and erysipelas were similar if not identical processes. It was observed 
that both were endemic in maternities at the same time, many cases of severe puer- 
peral sepsis began vrith erysipelas of the vulva, babies of septic puerperal patients 
became ill with erysipelas, doctors and assistants who cared for patients with erysipelas 
transmitted puerperal fever to recently delivered women, or during the care of patients 
with puerperal sepsis doctors or attendants themselves developed erysipelas. Virchow 
pointed out the similarity in the anatomic changes of both conditions. We know today 
that erysipelas and most cases of puerperal sepsis are caused by streptococci. Hence, 
it is easy to see why erysipelas of the vulva in a puerperal woman occasionally shows 
not only the usual skin manifestations but also spreads to the vagina, uterus and tubes 
and ends in a fatal peritonitis. Erysipelas in other parts of the body such as the face, 
runs its course during the puerperium just as it does in nonpregnant individuals and it 
does not necessarily endanger the genitalia. 

The treatment of erysipelas during pregnancy or tl>e puerperium is the same as in 
the nonpregnant state. 

A child should not be permitted to nurse at the breast chiefly because of the danger 
of infection of the umbilicus and also because the mother is frequently verj' ill. 

TYPHOID FEVER 

In spite of the frequency of typhoid fever, especially' a few years ago, the incidence 
of this disease during pregnancy is very low. Kiwisch in a series of 30,000 pregnancies 
saw only one patient with typhoid fever and at the Chicago Lying-In Hospital in almost 
35,000 confinement eases there was likewise only one case. Liebermeister among 1,420 
typhoid patients found 18 pregnant women (1.3 per cent) and Ziilzer among 1,852 
typhoid cases saw only 24 pregnant women (1.3 per cent). On the other hand, Vil- 
larama and Galang observed 64 eases of typhoid in pregnancy and the puerperium 
from 1917 to 1929 in Manila. Ehenter and Savoye reported nine cases in pregnancy 
and labor during an epidemic of typhoid fever in Lyon. M. Trancu-Eainer described 
in great detail the findings in the uterus of a woman who developed typhoid fever dur- 
ing the fifth week of pregnancy and who had a spontaneous abortion. 

According to De Lee the mortality is higher among pregnant women than among 
others. This is borne out by Drench who claims that the death rate for gravid women 
with typhoid is 12 per cent. In Villarama and Galang ’s series the mortality was 
31.3 per cent. Of the 20 women who died 11 were pregnant (26.1 per cent) and 9 were 
puerperal on admission to the hospital (45 per cent). Hence the death rate among the 
puerperal eases is much higher. 

In 60 to 80 per cent of the cases where typhoid is associated with pregnancy, the 
latter is interrupted spontaneously. Corbin found 232 interruptions among 364 re- 
ported cases, an incidence of 63.7 per cent. In Villarama and Galang 's^ series of 42 
pregnant women, pregnancy was interrupted in 78 per cent. The earlier in pregnancy 
typhoid sets in, the more certainly will the gestation be ended. Termination of gesta- 
tion does not cut short the disease, but of the 25 cases where pregnancy was interrupted 
by the disease, 21 patients (84 per cent) recovered. The uterus may empty itself in 
any stage of the disease even during the convalescence, but usually it does so in the 
second and third week of the illness. 

Typhoid has no appreciable effect on labor and the puerperium. If, however, typhoid 
sets in just before labor or during the puerperium it may easily be confused with puer- 
peral sepsis. However, in favor of typhoid are the absence of symptonas referable to 
the pelvic organs, leucopenia, roseola, relative bradycardia, characteristic stools, sero- 
diagnosis and bacterial examinations. Typhoid fever and puerperal sepsis may occur 
in the same patient and then the difSculty in making a correct diagnosis is very great. 

A study of the leucocyte count in Villarama and Galang 's series revealed that 17 
had a blood count of less than 7,000, 20 had between 7,000 and 10,000 and 20 (35 per 
cent) had more than 10,000 white blood cells. The relatively high incidence of leuco- 
cytosis was due to the physiologic leucoeytosis of pregnancy and also to complications 
such as puerperal infection (8), lobar pneumonia (14), acute nephritis (4), etc. A 
positive Widal test was obtained in 49 patients of this series. 

The fetus is infected in about half the cases and in contrast to the mother the in- 
fection is general and not intestinal. In Villarama and Galang 's series the fetal death 



REVIEWS AND ABSTRACTS 


T6T 


rate -was 50 per cent, distributed as follows : 2 abortions, 13 miscarriages, 1 stillbirth, 
and 5 deaths after delivery. In a certain proportion of cases, not only do the typhoid 
bacilli go over from the mother to the fetus but also immune bodies, especially ag- 
glutinins. In the cases where the fetus is infected, the disease has usually been present 
in the mother a long time while in the cases where the children are born alive and un- 
infected, the disease has usually been of short duration. 

During epidemics of typhoid, many mothers were vaccinated. They stood the vac- 
cination well but the children did not benefit by these vaccinations. Typhoid bacilli do 
not reach the mother 's milk but occasionally agglutinins are found in the milk. Hence 
a mother with typhoid may nurse her baby. However, since there are so many ways in 
which the mother can transmit the infection to her baby and since a mother with typhoid 
is usually too ill to stand the strain of nursing, the baby should be separated from its 
mother immediately after birth. 

The treatment of typhoid during pregnancy does not differ from the customary 
therapy of this disease. Artificial interruption of pregnancy is practically never indi- 
cated, although some authors suggest emptying the uterus when the child is viable, to 
prevent the passage of bacilli to the fetus. 

SMALLPOX 

Smallpox seldom is seen in pregnant women. However, when it does occur among 
pregnant women the danger is greater than it is among nonpregnant individuals as in- 
dicated bj' Table I given by J. Novak; 


Table I 


AUTHOR 

MORTALITY IN NONPREGNANT 

MORTALITY IN PREGNANT WOMEN 

Vinay 

1 

25% 

36% 

Willigen 

11% 

15% 

Knecht 

9% 

1 

35% 


Willigen found a mortality of 9 per cent for primiparas and 17.3 per cent for multip- 
aras, and this is probably due to the greater immunity of primiparas. 

Pregnancy is terminated in from 30 to 69 per cent of the cases and this may occur 
in any stage of the illness, but most frequently in the eruption stage. The further ad- 
vanced the pregnancy, the greater the likelihood of interruption. The cause of abortion 
and premature labor is not known, but it is probably hemorrhage in the decidua and 
primary death of the fetus. The average fetal mortality is 45 per cent. In most in- 
stances where the child is born healthy it remains so, but occasionally the disease shows 
itself a few days after birth. Intrauterine infection is common and a child may be 
born pock-marked as was Mauriceau, the famous French obstetrician. Some babies 
acquire the disease during labor and show signs of it after a thirteen- or fourteen-day 
incubation period. In a few cases, babies are born with smallpox though the mothers 
never showed any signs of the disease. 

In mild cases, labor is usually uneventful but in severe cases, hemorrhage frequently 
occurs. Likewise excessive bleeding during the puerperium is not uncommon. Because 
of the danger of sepsis, vaginal examinations and intrauterine manipulation should 
be avoided as far as possible. 

During epidemics of smallpox, pregnant women and their newborn babies should be 
vaccinated because no harm results from this procedure. Urner vaccinated 129 preg- 
nant women regardless of the month of pregnancy, and there was not a single case of 
threatened abortion, miscarriage, or premature labor. All the infants of these mothers 
were likewise vaccinated on the third day after birth with good results. Liebcrman re- 
ported a series of 351 pregnant women and their newborn babies who were vaccinated 
without bad consequences. All authors agree that vaccination of the mother during 
pregnancy resulting in a positive reaction does not convey any specific immunity to the 
kaby. In Lieberman’s series 71 per cent of the infants reacted with positive scars 
and in a series of 684 vaccinations in the newborn reported by Mensching, exactly the 
sa:ne percentage showed positive results. Even premature babies stand vaccination 
well. 









768 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


Contrary to these findings in the human being, are the animal experiments of Ohta- 
■vvara. He vaccinated pregnant rabbits to see if the newborn would acquire an im- 
munity against smallpox. The findings were positive and this author believes the 
immunity of the newborn is an active one. In spite of this, in cases of smallpox it is 
best to separate the newborn baby from its mother immediately after birth. 

Smallpox in the puerperal woman is treated in the same way as it is in other 
individuals. 

CHICKENPOX (VAEICELIiA) 

Chiekenpox in pregnancy or the puerperium is an extreme rarity. Myers reported a 
case which occurred during the puerperium. The lesions were chiefly on the labia 
majora and the breasts. Varicella ma 3 ' be transmitted to the child in utero as evi- 
denced by the case of Hubbard and Wells where the newborn showed typical chiekenpox 
twenty-four hours after birth. The mother remained well. The child may become 
infected at the time of labor as occurred in the case of Lereboullet and Moricaud in 
which the mother manifested chiekenpox the day of labor and the child showed it 
fourteen days after birth. Ehenter and Mamas report a case where a woman mani- 
fested chiekenpox eleven days after labor, and the child showed typical varicella 
fourteen days later. 

Chiekenpox is harmless to both mother and child. Treatment is the same as in non- 
pregnant individuals. 

MEASLES 

Measles during pregnancy is usually serious because this disease frequently has a 
grave prognosis for adults. It may occur at any time during gestation and Hellner, who 
collected 30 such cases, reports a maternal mortality of 15 per cent. In Nouvat’s series 
of 84 cases the death rate was 14 per cent. 

Labor is usually normal but the puerperium is frequently complicated by diseases 
of the respiratory system and puerperal infection. Among the causes of death, pneu- 
monia ranks first and following this are inflammatory changes in the endometrium and 
peritoneum which occur during the puerperium. 

Pregnancy is interrupted in a large proportion of cases, the incidence reported by 
different authors varying from 45 to 76 per cent. The uterus usually empties itself 
in the exanthematous stage. TJie prognosis for the children is grave ivhen pregnancy 
is interrupted. Esch reported a fetal mortality of 52.4 per cent. If a mother with 
measles gives birth to a healthy child without signs of the disease, the child will remain 
well even if it nurses its mother. Most newborn babies are immune to measles and this 
immunity lasts about tluee to five months. The immunitj' is usually due to transmis- 
sion of antibodies through the placenta because most mothers have had measles. 

Intrauterine diaplacental transmission of measles to the fetus does occur. In 
Nouvat’s series of 84 cases the disease was transmitted to the child 21 times, or in 
25 per cent of all the cases. Of the 21 babies, 13 showed the disease at birth and 8 after 
delivery. Of the former, 4 died (30.8 per cent) and of the latter 2 died (25 per cent). 

The treatment of measles during pregnancy does not differ from the usual therapy. 
During epidemics of measles, pregnant women should be protected against the disease 
but there need not be strict isolation. De Lee, in his service at the Chicago Lying-In 
Hospital has seen many pregnant women who were exposed to tliis contagion from their 
sick children at home but in only one case did measles develop. This shows that even 
the imperfect isolation which is possible in the homes of the poor suffices to protect the 
mothers. 

ENCEPHALITIS LETHABGICA 

Within the two or three years following the 1918 epidemic of influenza, many cases 
of encephalitis lethargica were observed, and a fair number of these patients were 
pregnant or had recently been delivered. However, in almost 35,000 puerperal patients 
seen at the Chicago Lying-In Hospital, there was only one case of encephalitis lethar- 
gica. Eoques collected from the literature 201 cases of encephalitis complicating preg- 
nancy of which 171 were of the acute and the rest of the chronic type. 

More cases of encephalitis are found among primiparas than among multiparas, but 
chiefly because young women are more likely to contract this disease than older women. 
The infection is more common in the later months and after delivery than in the first 
half of pregnancy. There is no agreement concerning the effect of pregnancy on the 
incidence of the disease but large statistics prove conclusively that pregnancy does not 
increase the susceptibility to it. 

The mortality among pregnant women has been variously estimated to be from 5 to 
70 per cent. The large variations are due to the difference in the number of cases 



REVIEWS AND ABSTRACTS 


769 


observed, the year and time of the year, the country and the virulence of the disease. 
Of 170 cases in pregnancy collected from the literature by Eoques, the mortality was 
42 per cent and this was about the same as for all persons attacked under similar con- 
ditions of age, sex, and locality. The death rate for encephalitis in Germany was 25 per 
cent, in Italy 21 per cent, in Prance 25 per cent, in Switzerland 29.4 per cent and in 
England 40 per cent. In Roques ’ own series of 21 cases the death rate was only 5 per 
cent. The mortality is somewhat greater when encephalitis occurs early in pregnancy 
and it is slightly higher in multiparas. 

The symptoms are the same in pregnancy as in nonpregnant individuals during the 
same epidemic. Labor in some cases produces marked aggravation of the symptoms 
whereas in others improvement is noted. In the largest number of patients, however, 
there is no change in the woman ’s condition after delivery. 

In the majority of cases pregnancy goes to term without any mishap. In severe 
cases pregnancy is sometimes spontaneously interrupted and in the patients who are 
extremely ill death occurs before the uterus can empty itself. 

Labor and the puerperium are not complicated in any way by encephalitis, but labor 
is usually painless. 

Encephalitis must be differentiated from the toxemias of pregnancy, such as 
eclampsia and hyperemesis gravidarum and also from chorea and grippe. Pregnant 
women with encephalitis are not more likely to develop the toxemias of pregnancy. 

Most continental authors claim that fetal death before term is common whereas 
most British authorities deny this. A difference in virulence may explain this diver- 
gence of opinion. 

The fetal mortality varies directly with the stage of gestation and the maternal issue. 

Eoques publishes the following table (Table II). 

Tabus II 


FETAL 

MORTALITY 


1. Eatal maternal infection before sixth month 100% 

2. Nonfatal maternal infection before sixth month 37% 

3. Eatal maternal infection after sixth month 68% 

4. Nonfatal maternal infection after sixth month 22% 

5. Eatal maternal infection during puerperium 14% 

6. Nonfatal maternal infection during puerperium 7% 


The total fetal mortality was 46 per cent. If an infant survives the first few weeks 
of life, there is little likelihood that it will subsequently acquire the disease. Enceph- 
alitis epidemica neonatorum though rare, exists as an entity but the mortality is not 
high. The virus can pass through the placenta, hence some babies can become infected 
before birth. However, there is little to substantiate the belief that infection of the 
child may take place through the mother ’s mUk. 

The disease should be treated in the same way as in the nonpregnant state. It is 
not advisable to interrupt pregnancy because neither abortion nor labor produces any 
change in most cases. Conservative therapy can nearly always be carried out with good 
results. Obstetric operations on these patients are dangerous and have a high mor- 
tality, but occasionally cesarean section is advisable. Patients should be carefully 
watched for the onset of labor, because labor may be completed without the knowledge 
of anyone due to the absence of pain. This increases the risk to the child. Breast nurs- 
ing should not be permitted, because it is too much of a drain on the mother. 

In a certain proportion of cases, acute encephalitis passes into the chronic state of 
Parkinson disease. According to Bland and Goldstein the literature leads one to the 
conclusion that at least 75 per cent of patients with acute encephalitis in pregnancy 
develop symptoms of paralysis agitans whereas the incidence of the chronic state after 
ordinary acute encephalitis is not more than 25 per cent. In general, pregnancy has 
a distinctly unfavorable effect on the chronic disease, but some patients have a normal 
pregnancy and labor and suffer no change in their condition. Pregnancy is not usually 
affected by Parkinson disease but in the severe cases, premature labor usually occurs. 
Labor is nearly always associated with less pain than in normal individuals. Puerperal 
coniplications are unusual and the child does not suffer as the result of chronic enceph 
alitis in the mother. 




770 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGT 


Prophylactically patients wlio recover from an attack of acute eneeplialitis or from 
Parkinson disease should be cautioned against becoming pregnant for at least four 
years after recovery. 

MENINGITIS 

Epidemic meningitis during the puerperal state is uncommon and is practically 
always fatal. At the Chicago Lying-in Hospital in almost 35,000 labor cases, there was 
only one case of pneumococcus meningitis. In the literature up to 1910 Commandeur 
could find only 9 cases of purulent meningitis among pregnant women. The organism 
most commonly found is the pneumococcus. In the puerperium the usual source of 
origin is infected genitalia from which the infection reaches the meninges through the 
blood stream. A number of cases have been reported where newborn children of 
mothers with meningococcus meningitis also had meningitis; but thus far it has not 
been demonstrated that the meningococcus can pass over to the fetus in the uterus. Laf- 
font and Mele report a case of fatal septicemia with meningitis where the responsible 
organism was the staphylococcus and this organism did pass through the placenta. 

Tuberculous meningitis may also occur during gestation. Couvelaire and Lacomme 
report four cases which were observed among 600 women who were admitted to the 
special maternity for tuberculous patients attached to the Baudeloque clinic. Gaujoux 
and Boissier describe an additional case and analj'ze the 26 cases reported in the litera- 
ture. One ease of tuberculous meningitis was seen at the Chicago Lying-in Hospital. 

Meningitis may rarelj- occur during puerperal sepsis and at autopsy in these cases 
very few anatomic changes are usually found. 

In the early months of pregnancy, meningitis, especially the tuberculous tj’pe, maj 
be mistaken for hyperemesis, whereas in the later months it may be difScult to dif- 
ferentiate from eclampsia, grippe, typhoid, encephalitis, and cerebral hemorrhage. 
Urinalysis and blood pressure readings will help to determine the diagnosis but a 
lumbar puncture is most essential. Lush reports a case of meningitis during pregnancy 
where hemorrhage in the meninges was a manifestation of pregnancy toxemia com- 
parable to the hemorrhages which occur in the liver and kidneys during toxemia. The 
patient recovered after spontaneous emptying of the uterus. 

The treatment of meningitis during pregnancy is not influenced by the presence of 
the gestation. The disease does not have a tendency to interrupt the gestation nor 
favor the onset of premature labor. Children born of mothers with tuberculous menin- 
gitis are not necessarily infected in utero, but the proportion of infected babies is 
greater among these mothers than among mothers who have pulmonary tuberculosis. 

Meningitis at or near term is an indication for immediate postmortem cesarean 
section. 

TETANUS 

Tetanus is one of the most serious wound complications, and puerperal tetanus is 
perhaps the most dangerous of all. Spiegel, in 1915, collected 65 cases and found 
that 54 patients had died, a mortality of 83.1 per cent. Schneider was able to collect 
111 cases reported up to 1925, including two of his own, and the total mortality was 
91 per cent. Sommer found ten more cases up to 1929. Since the extensive use of 
tetanus antitoxin, the mortality has been reduced, but it is still frightfully high. ^ Dur- 
ing pregnancy the period of incubation varies from four to twenty-one days with an 
average of nine days. This is shorter than the incubation period in nonpregnant in- 
dividuals, and this is due to the favorable absorptive processes in the puerperal uterus. 
The shorter the period of incubation, the more dangerous the disease. Puerperal tet- 
anus is especially serious because the cramps frequently affect the pharyngeal muscles 
early, then they involve the respiratory muscles and cause death from choking. 

Prophylactic measures against puerperal tetanus are very reliable, but the treat- 
ment of the condition after it has broken out is most ineffective. In eases where there 
is danger that tetanus may occur, prophylactic doses of tetanus antitoxin should be 
given regardless of the presence of pregnancy. Since the effect of the antitoxin does 
not last more than a week, the injections should be repeated. The later the antitoxin is 
given the larger the dose must be. In general the treatment is the same as for non- 
puerperal individuals. Eemoval of the uterus has been tried but the results lia%'e not 
been encouraging. 

Ten Broeck and Bauer found that when tetanus antitoxin is present in the mother's 
blood serum, it is also to be found in the cord blood of the baby. In most cases, the 
amount of antitoxin in both bloods is the same. Colostrum also contains the tetanus 
antitoxin hence infants may receive a supply of antitoxin through the mother’s milk. 
However, the serious condition of the mother is usually a contraindication to breast 
feeding. 



REVIEWS AND ABSTRACTS 


771 


In Peiping approximately one-third of the people are carriers of tetanus bacilli but 
there is a comparatively low incidence of tetanus. In Hawaii according to Milnor 
tetanus is very prevalent and the death rate is about 92 per cent. Puerperal tetanus, 
however, is less common than that due to punctures iu the foot and hand. 

The only ease observed at the Chicago Lying-in Ho.spital was in a patient delivered 
at home by a midwife. Just before death the dispensary servifee was sent for. 

WHOOPING COUGH 

Whooping cough is rare in adults hence it is very infrequent during pregnancy. 
Only one case was observed in almost 35,000 labors at the Chicago Lying-in Hospital. 
The severe coughing associated with this disease may cause rupture of the membranes 
and premature interruption of pregnancy. 

The treatment of pertussis during pregnancy is the same as usual. Hrabouky cured 
whooping cough in a pregnant woman near term by means of x-ray treatments. A 
normal child was born at term. 

Intrauterine infection of the fetus has not yet been proved. The baby should be 
separated from its mother immediately after birth because it has no immunity against 
the disease and because of the great danger of bronchopneumonia which is nearly 
always fatal. 

Phillips reported two cases of pertussis contracted at birth and in both cases the 
infection was contracted from an obstetric nurse who was in the first week of the at- 
tack of whooping cough. This author saw six cases of pertussis in three different 
families within one year and all were contracted from nurses who had coughs which 
they considered to be ordinary “colds.” A nurse with a cough should not take care 
of obstetric patients. 

MUMPS 

Although orchitis occurs as a complication in about 30 per cent of males who have 
epidemic parotitis, involvement of the ovaries in women is rare. It may occur more 
frequently than is supposed but we have no way of recognizing it definitely because it 
is usually symptomless. When mumps affects the ovaries it produces painless changes 
without any alteration in size. Daleas reports a pregnancy after oophoritis associated 
with mumps. He mentions that Naudin who reported the persistence of menstruation 
in 28 women after an attack of mumps did not observe a single pregnancy among them. 

There are only a few case reports in the literature of the occurrence of mumps dur- 
ing pregnancy. In one case at least the disease was transmitted to the newborn baby. 
There was only one case of mumps at the Chicago Lying-in Hospital in almost 35,000 
deliveries. Moore recently reported a case which complicated late pregnancy. 

PLAGUE 

Very little is known about the occurrence of plague during gestation. Pregnancy is 
usually interrupted by the disease, as proven in many epidemics. However, Laurentie 
and Tyan believe that gestation is interrupted only when there is a generalized infec- 
tion. If the disease remains localized, pregnancy continues unmolested. The disease 
has a bad prognosis for both mother and child because the estimated mortality for the 
mother is about 80 per cent and for the child about 88 per cent. The mother sometimes 
dies before the fetus is expelled. Some babies which are born alive and healthy remain 
so. Three fetuses which were obtained in intact membranes were examined by the 
German Plague Commission and found to have parencymatous degeneration and hemor- 
rhages of the viscera but no organisms could be detected. Hence fetal death is most 
likely due to toxins. 

The puerperal state does not aggravate the disease and vice versa, plague has no 
special effect on labor. There may or may not be complications during the puerperium. 

Laurentie and Tyan administered antiplague serum to a pregnant woman with 
plague and she recovered. The child was permitted to nurse at its mother ’s breasts and 
it remained healthy. This was one of six cases seen by the authors in an epidemic at 
Beyruth. All six patients recovered and there was only one abortion. The other five 
babies were born alive and healthy. The authors advise that patients should be given 
serum treatment regardless of the presence of a pregnancy. 

ANTHRAX 

ilany cases of anthrax complicating pregnancy have been reported and most of them 
ended fatally (Schmorl, !Marchand, Hiinicken, etc.). In some cases, there is premature 
interruption of the gestation and in others death occurs before the uterus is emptied. 



772 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


In most cases tlie disease has its origin in a sMn injury and begins with the well known 
malignant pustule. It may also begin in the lungs or in the intestines. In pregnant 
women as Yuth others, it is nearly always possible to obtain a history of contact with 
infected animal matter such as skin, leather, spleen, hair, etc., from which the infec- 
tion was derived. In all but three cases reported iu the literature, the children were 
born dead or died shortly after birth. In some cases anthrax bacilli were found in the 
fetal organs. 

In animal experiments it has been found that anthrax baciUi frequently but not 
always pass from an infected mother to the fetus. The bacilli have also been found in 
the milk of infected animals. 

There are reports in the literature of seven cases where the disease was transmitted 
from the mother to the fetus within the uterus. In at least foim of these cases, there 
was a pustule on the face of women who were apparently healthy, yet the blood 
cultures showed large numbers of anthrax bacilli. 

If a baby is born alive, it should not be permitted to nurse its mother for the 
mother ’s sake as well as its own. 


REFERENCES 

AM; J. A. M. A. 72: 980, 1910. Adair and Tiber: Am. J. Obst. & Gynec. 17: 559, 

1929. Backaus: Quoted by Campbell. Baer and Ries: Surg-. Gynec. Obst. 32 : 353,1921. 
Bland: Am. J. Obst. & Gynec. 70 : 184,1919. Bland and Goldstein : J. A. M. A. 05: 473, 

1930. Bourut: Quoted by Novak. Bumni: Quoted by Novak. Burr: Am. J. Obst. & 
Gynec. 17: 653, 1929. Gamvbell: Am. J. Obst. & Gynec. IC: 881, 1928. Gasaveocliia: 
Gazz. de osp. Milana 22: 605, 1901. Gonimandcur: Zentralbl. f. Gynak. 34: 1085, 1910. 
Corbin: Quoted by Novak, p. 674. Couvclaire and Lacomme: Gyngc. et Obst. 10: 1, 
1929. Daleas; Bull, de la Soc. d’Obst et de Gyngc. S: 583, 1927. de Lavergne and 
Pruliinsholz ; Gjmgc. et Obst. IS: 450, 1928. De Lee: Principles and Practice of Ob- 
stetrics, ed. 5, Philadelphia, 1928, "W. B. Saunders Co. Devraigne, Baize, and Mayer: 
Bull, de la Soc. d’Obst. et de Gyngc. 18: 337, 1929. Ehrlich: Ztschr. f. Hyg. 12: 183, 
1892. Each: Zentralbl. f. GyntLk. 42: 105 and 121, 1918. Fellner: Quoted by De Lee. 
French: Quoted by Trancu-Rainer. Gaujoux and Boissier; Rev. frang. de Gyngc. et 
d’Obst. 2G: 591, 1931. German Plague Commission: Quoted by Novak. Gocht; Quoted 
by Novak. Gourfein; Quoted by Novak. Sarris: J. A. M. A. 72: 978, 1919. Hersh: 
Am. j. Obst. & Gynec. 23: 133, 1933. Hrabottsky : "Wien. klin. "Wchnschr. 30: 422, 1927. 
Bubbard and Wells: Brit. M. J. June 8, 1878. Biinicken: Berl. klin. "Wchnschr. 46: 
473, 1868. Jurgensen: Notlmagel Spez. Patli. u. Therap. 1896, 4. Jurgensen: Quoted 
by Weinberger in Halban Seitz Biologic und Patholog'ie des Weibes 5: 725, 1928. 
Karlbaum; Zentralbl. f. Gynhk. 43: 313, 1919. Kiniisch; Quoted by Freund in Von 
Winckel’s Handbuch der Geburtshilfe 2: 1, 554, 1904. Laffont and Mele; Bull, de la 
Soc. d’Obst. et de Gyngc. 0: 566, 1926. Laurentie and Tyan: Bull, de la Soc. d’Obst. et 
de Gyngc. C: 403, 1926. Lereboullet and Moricaud: Arch, de Med. des enfants 17; 228, 
1914. Lieberman: AM. J, Obst. & Gynec. 14: 217, 1927. Liebermeister: Quoted by 
Freund. Litivak; Arch. f. Gynhk. 148; 453, 1932. Lush: Lancet 211: 1006, 1926. 
Marchand; Virchows Arch. 1: 520, 1886. Mensching: Arch. f. Kinderh. 68: 24, 1920. 
Milnor: AM. J. Obst. & Gynec. 16: ill, 1928. Moore: J. A. M. A. 97: 1625, 1931. 
Myers: Brit. M. J. March 2, 1912. Nonvat: Rougeole et Grossesse, Th&se de Bordeaux, 
1904. Novak: in Halban-Seitz Biologie und Patliologie des Weibes 5: 665, 1928. 
Ohtavjara: Japan. Med. Worid 2: 254, 1922. Olshausen: Arch. f. Gynak. 9: 169, 1875. 
Ottow: Zentralbl. f. Gynhk. 43: 7, 1919. Pfaundler: Arch. f. ICinderh. 46: 260, 1908. 
Phillips: Am. J. M. Sc. 161: 163, 1921. Poach: Ztschr. f. Geburtsh. u. Gynak. 90: 609, 
1927. Ranson: J. A. M. A. 52: 556, 1909. Rhenter and Marnas : Bull, de la Soc. d’Obst. 
et de Gyngc. 20: 717, 1933. Rhenter and Savoye: Bull, de la Soc. d’Obst. et de Gyngc. 
IS: 242, 1929. Rogues: J. Obst. & Gynec. Brit. Emp. 39: 1, 1928. Royston: Am. J. 
Obst. & Gynec. 1: 941, 1921. Runge: Arch. f. Gynak. 12: 16, 1877. Schmidt: Wiener 
Med. Wchnschr. 23: 42, 1926. Schmitt: Quoted by Seitz. Schmitz: Quoted by Novak. 
Schmorl: Zentralbl. f. Gynak. 15: 431, 1906. Schneider: Med. kiln. 22: 134, 1926. 
Seitz: Handb. d. Geburtsh. 2: 269, 1916 (Bergmann, Wiesbaden). Sif/ioort: Ifelban- 
Seitz Patliologie und Biologie des Weibes, 8: 691, 1927. Sommer: Zentralbl. f. Gjmak. 
53; 2394, 1929. Spiegel: Arch. f. Gynak. 103: 367, 1915. Spiegelberg: Quoted by Roy- 
ston. Steen: Brit. M. J. 1: 575, 1900. Stolz: Nothnagel’s Handb. der Sp^. Path. u. 
’Ther. 1913. Stookey and Downs: Am. J. Obst. & Gynec. 23: 735, 1932. Ten Broeck 
and Bauer: Proc. Soc. Exper. Bioi. & Med. 20: 399, 1923. Trancii-Rainer: Ztschr. f. 
Geburtsh. u. Gynak. 98: 299, 1930. Brner: Am. J. Obst. & Gynec. 13; 70, 1929. 
Vignes: Rev. gen. de din et de thgrap. 43; 801, 1929. Vinay : Quoted by De Lee, p. 520. 
Virchow: Quoted by Novak. Villarama and Galang: J. Philippine Islands Med. Assn. 
10: 311, 1930. Willson and Preece: Arch. Int. Med. 40: 471, 1932. Zulzer: Quoted by 
Freund. 


Erratum 

In the article by Samuels and Edlaviteh in the March issue, on page 399, last sentence 
in the third paragraph, the percentage of mortality reported by Burch and Burch 
should read 4.6 instead of 7.5. 



Selected Abstracts 


Eclampsia 

Olsen, A.: Examinations of Renal Eunction in Eclampsia and Allied Toxemias, Acta 

Obst. et Gfynec. Scandinav. 12: 164, 1932. 

A summary is given of the views of different periods and changing theories concern- 
ing the nature of the Icidney of pregnancy and its importance in the pathogenesis of 
eclampsia, and an account is given of the diversity of opinions as to the nature of this 
disease. 

As both hypertension and the tendency to edema formation in pregnancy can occur 
without any kidney disease, it is necessary in the classification of the kidney of preg- 
nancy to lay the main stress on function, but kidney function in cases of eclampsia and 
kindred conditions must be compared with the function in normal pregnant women, not 
with the function in normal nonpregnant persons. 

In normal pregnant and parturient women 353 determinations of urea and 74 de- 
terminations of N.P.N. were made, and it was shown: that (1) in normal pregnant 
women urea is lower than in normal nonpregnant persons, and that the difference is so 
considerable, that it must be biologically conditioned; (2) the N.P.N. is reduced in nor- 
mal pregnancy, but only by the quantity of N which corresponds to the reduction of 
urea; (3) in urea there is no certain difference between the successive fortnightly pe- 
riods during the last 10 weeks of pregnancy or in parturition. 

In 44 pregnant and parturient women suffering from hypertension, 54 from albumi- 
nuria, 34 from hypertension plus albuminuria, 42 from hypertension plus albuminuria 
plus edema, 24 from preeclampsia and 27 from eclampsia (besides 13 with various other 
complications of pregnancy) 1100 determinations of urea and 300 determinations of 
N.P.N. were made. These investigations show that (1) in all the groups there is an in- 
crease of urea as compared with the normal figure, and that the difference — ^with the ex- 
ception of the first group — is so great that it must be biologically conditioned; (2) this 
difference increases from group to group but even in cases of eclampsia pathologic 
values are rarely seen and sometimes even low ones; (3) in cases of eclampsia and pre- 
eclampsia a considerable increase of urea (up to 151 mg. per cent) is generally seen dur- 
ing the first days after delivery, whereas an increase is rare in the other groups; (4) 
fever, narcosis, hemorrhage and pyuria can be left out of account as causes of the in- 
crease observed. 

To make a distinction between uremia caused by overproduction and uremia caused 
by retention, direct examinations of the kidney function are necessary. 

The results of functional tests made are as follows: (1) Among normal pregnant 
women two types may be distinguished: One with slightly increased, the other with 
slightly reduced function in comparison with normal nonpregnant persons. During 
pregnancy, therefore, the limits of what is normal must be drawn somewhat wider than 
outside of it. (2) During pregnancy — even in cases of considerable hypertension, 
serious albuminuria and generalized edema — no ease of certain reduction of renal func- 
tion was observed without simultaneous cerebral symptoms. (3) In cases of eclampsia 
and preeclampsia there is during the first days following delivery in 85 per cent of all 
cases a reduction of kidney function, which during the first period after delivery or dur- 
ing the Stroganoff treatment is often of such a degree as to suggest a discontinuation of 
the function. J. p. Greexhill. 


773 



774 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


Konrad, E.: The Effect of Atmospheric Changes on the Incidence of Eclampsia, 

Arch. f. Gynak. 143: 9, 1930. 

Konrad observed nine patients -who developed eclampsia on days when the relative 
humidity of the air was more than 20 per cent. Two other cases, which terminated 
fatally, occurred on days when the relative humidity was 20 to 30 per cent. The author 
is of the opinion that a definite cause and effect relationship exists between the moisture 
content of the air and the relative frequency of eclampsia. A severe winter accompanied 
by a heavy snowfall, followed by rapid melting in the spring results in increased humid- 
ity and one must therefore expect an increase in the eclampsia incidence. 

Ealph a. Eeis. 

Theobald, G. W.: The Causation of Eclampsia, Lancet 218: 1115, 1930. 

Eclampsia is considered a syndrome, and its individual features are attributed to the 
absorption of toxins from the intestines which are in a partial state of stasis. The ac- 
tion of the disease is due to : hypoglycemia, edema of or hemorrhage into the brain, or 
toxins acting directly or indirectly upon tlie nervous system. Calcium acts as a protec- 
tor, provided enough is ingested and sufficient vitamin D is present to allow the utiliza- 
tion of the mineral. 

The author’s experiments on dogs produced convulsions and in certain instances com- 
parable liver and kidney lesions. Intravenous injections of feces, eclamptic blood, oxy- 
lates, or guanidine carbonate, and also the separation of the placenta were fruitless. A 
lean meat diet, even though sufficient vitamins were present, lacking in calcium did not 
prevent parenchjunatous lesions. Since the animal experiments supported his hypoth- 
esis the writer believes that eclampsia is prevented by the adequate use of calcium and 
vitamin D, especially in the absence of intestinal stasis. 

This theory is supposed to explain all the known facts concerning this disease. 

H. 0. Hesseltinb. 

Brown, E. Christie: The Intestinal Origin of Eclampsia, Brit. Med. J. 2: 859, 1930. 

It is found clinically that the kidney is excreting albumin and is no longer acting as 
an efficient barrier to the blood colloids. Similarly the liver may cease to act as a bar- 
rier between the portal and systemic circulation. Thus the toxin is allowed to pass un- 
changed into the systemic circulation producing a secondary toxemia which may be the 
origin of the fits. 

On the basis of the above theory, Pavlov in his experiments on dogs with their portal 
circulation cut off from the liver and sending it directly into the systemic circulation 
was able to produce convulsions and coma by feeding a high protein diet. 

The above is explained on the basis that the liver acts as a detoxicator of poisonous 
substances carried by the portal vein. It has been pointed out by Gibbon Eitzgibbon 
and confirmed by the author that the eclamptic patient usually suffers from constipa- 
tion and dietetic excess and her detoxicator, the liver, is damaged, wliieh on analogy 
with the kidney may allow noxious substances from the portal vein to pass into the gen- 
eral circulation. L. Adaie. 

Seitz, L.: The Prophylaxis and Treatment of Eclampsia and Preeclampsia, Arch. f. 

Gyniik. 142: 52, 1930. 

The most effective means of intelligently combating eclampsia is by active and intel- 
ligent prophylaxis. It is possible to greatly decrease and almost entirely eradicate pre- 
eclamptic symptoms by a careful regulation of diet, especially the vitamines, control of 
the protein intake and output, salt regulation and the avoidance of heavy physical labor. 
Nephropathies and preeclampsias should be treated by starvation for two to three days 
followed by saltfree diet and bedrest. If the symptoms improve this line of treatment 
may be safely continued. The pregnancy must be interrupted immediately, however, if 



REVIEWS AND ABSTRACTS 


775 


tlie symptoms remain stationary or become Tforse. The most important criteria of fail- 
ure of improvement are a decrease in galvanic sensitivity, an increase in bloodpressure 
and a continnation of the subjective symptoms. In true eclampsia the pregnancy must 
be terminated at once, by forceps if dilatation is complete, otherwise by cesarean section. 

Ealph a. Eeis. 

Bissmann, P.: The Prevention and Treatment of Eclampsia on the Basis of 111 

Observations, Med. Klin. 26: 383, 1930. 

The author believes that eclampsia is caused by disturbances in the metabolism which 
are produced by pregnancy plus an alimentary factor. This he believes is borne out by 
the fact that none of the patients who follow out his diet develop eclampsia. He recom- 
mends a vegetable diet, and forbids strong spices, alcohol in large amounts, meat and 
raw eggs. Every woman who develops eclampsia has a venesection of at least 500 c.c. 
of blood and she receives luminal. Magnesium sulphate is no longer given but labor is 
hastened, especially by cesarean section. The latter operation was performed in 20 per 
cent of the author’s cases. His gross maternal mortality among 111 cases was 6 per 
cent and the fetal death rate was 18 per cent. J . P. Gueenhill. 

Schmechel, Arthur: Kecurrent Eclampsia, Zentralbl. f. Gyniik. 53: 2405, 1929. 

An attempt was made by means of a questioimaire to follow up 238 cases of eclamp- 
sia occurring in the course of 27,340 births at the Dresden Frauenklinik between the 
years 1915 to 1927, with the following statistics: 37 cases died primarily, with eclamp- 
sia; 2 cases died in the next few years, causes unknown; 41 eases were not located; 158 
cases replied to the questionnaire. 

Of these 158 cases, only 83 had more pregnancies, as follows: 35 had no eclampsia, 
42 per cent; 33 had preeclamptic symptoms, 40 per cent; 15 had recurrent eclampsia, 
18 per cent. 

These statistics are in accord with those published by Zangemeister, who found an 
incidence of 15 per cent of recurrent eclampsia in 76 cases, and do not coincide at all 
with incidences of 1.5 per cent and 3 per cent reported by other writers, (Lichtenstein, 
Biittner, Olshausen, Goedecke, Benthe, and others) . 

The question arises as to whether the cases of recurrent eclampsia were not in reality 
due to chronic nephritis. The author claims that they were not, and cites the fact that 
eclampsia is known to recur after a patient has had a normal birth without eclampsia 
(this happened in his series). He states that in only one out of 160 of his cases was a 
true chronic nephritis found. 

The writer believes that recurrent eclampsia runs a milder course, for there was only 
one death in his 15 cases, and that was due to premature separation of a normally im- 
planted placenta. William F. Mengeet. 

Kobes, Budolf : The Late Kesults in Cases of Eclamptic and Preeclamptic Women, 

Zentralbl. f. Gynak. 54: 666, 1930. 

Thirty-two cases of eclampsia, ante, intra, and postpartum, and 19 of preeclampsia 
were studied from the standpoint of late results. Of the eclamptics 29 were delivered 
operatively, 19 by section, 8 by forceps, and 2 by version. On discharge, about the 19th 
day, there was no pressure more than 135 mm., there was albumin in 11 cases and casts 
in 7, but none of the patients had edema. Check-up examinations, which included blood 
pressure, Volhard’s concentration test, and nitrogen determinations, three to eighty- 
live months after the appearance of the disease did not show evidence of a single case of 
residual nephritis. 

Of the 19 preeclamptics 15 were delivered operatively (including 2 manual dilata- 
tions and 2 craniotomies). Of these 19 cases 13 had previous histories of kidney dis- 
ease. In general, the author found that in this series of so-called preeclamptics, com- 
plete recovery was not so satisfactory as in the outspoken eclamptics. Two of the pre- 



776 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


eclamptics showed definite chronic nephritis, and 2 others showed irreparable retinal 
damage. The author states that in this latter series of cases it was impossible to rule 
out previous kidney disease unrelated to pregnancy because of unreliable histories. 

William F. Mengert. 

Elaften, E.: Detachment of the Eetina in Eclampsia, Med. Klin. 27: 588, 1931. 

According to Klaften, since 1855 when von Graefe described the first case of de- 
tachment of the retina there have been only 60 such cases reported associated with ret- 
initis of pregnancy. In recent years with more frequent ophthalmoscopic examinations 
of pregnant women with renal disturbances and eclampsia, we know that the eye grounds 
show many changes and of varied severity. The most important and the most serious 
are retinitis, neuroretinitis and ablation of the retina. During the last ten years among 
25,000 labor cases and among 206 cases of eclampsia, the author observed many in- 
stances of albuminuric retinitis, neuroretinitis, papillitis, edema of the retina and hem- 
orrhagic retinitis. However, he encountered only one case of detachment of the retina. 
It is characteristic for these pathologic conditions to retrogress rapidly. 

He agrees with those who maintain that detachment of the retina is an absolute in- 
dication for the termination of pregnancy. The earlier the interruption the more rapid 
and complete is the return of vision. Since in all of these patients the blood pressure is 
very high, there is danger of apoplexy. Furthermore in all of these cases, sooner or 
later, eclampsia or eclamptic uremia develops. J. P. Greenhill. 

Kuestner, H.: Eclampsia in Saxony in the Last Ten Tears, Arch. f. Gynak. 145:| 

577, 1931. 

For the last ten years the law in Saxony requires that eclampsia be reported and 
Kuestner is therefore able to report the statistics for all eclampsias occurring from 
1920-30. The number of births per year has dropped from 122,940 to 83,750 but eclamp- 
sia has increased from 194 per year to 238. The frequency in 1920 was 1 in 640 and in 
1930 was 1 in 350. The average for the ten year period was 1 in 430. The author be- 
lieves this marked increase to be due to the marked increase in meat consumption. In 
the metropolitan areas the incidence is 1 in 380 and in the rural districts 1 in 580. These 
differences the author attributes first to dietary differences, secondly to the differences 
in exposure to ultra-violet rays and sunshine and thirdly to differences in muscular ac- 
tivity which produce differences in metabolism. 

The smallest incidence was found in the first half of July, August and October and 
the greatest frequencies in the second half of April, July and December. The incidence 
was also found higher when the fetus was a male and higher in multiple than in single 
pregnancies; 78 per cent occurred in primiparae with a 13 per cent mortality, 11 per 
cent in secundiparae with a 20 per cent mortality and 12 per cent in multiparae with a 
23 per cent mortality. 

Spontaneously delivered were 25 per cent and by forceps another 25 per cent. The 
gross mortality was 15.7 per cent, being 16.4 per cent for the spontaneous and 15.2 per 
cent for the forceps group. Ralph A. Eeis. 

Thulin, E.: The Treatment of Eclampsia at the Gothenburg Maternity From 1918 

to 1928, Acta Obst. et Gynec. Scandinav. 9: 554, 1930. 

The author reviewed the results of treatment in 167 cases of eclampsia. During the 
years 1918-19 there were 42 cases and the treatment was active. The maternal mortality 
was 7.1 per cent and the fetal death rate was 25 per cent. During 1920-28, 125 patients 
were treated individually, according to the middle line therapy. The maternal death 
rate was 11.2 per cent and the fetal mortality was 29.5 per cent. J. P. Gbeenhill. 

Klaften, E.: Eclampsia, Arch. f. Gynak. 146: 386, 1931. 

Klaften reports the occurrence of eclampsia at the Peham clinic in Vienna during the 
last ten years, there being 178 cases from 1921 to 1928 and 28 cases from 1928 to 1930 



REVIEWS AND ABSTRACTS 


777 


inclusive. This marked decrease in the incidence of eclampsia is one •which has been 
noted by other observers and is due to increased prenatal care and to increased efficien- 
cy in prophylaxis. The mortality rates sho'w the same marked decrease there being 
13 deaths among the 178 patients but only 1 among the last 28. The total maternal 
mortality -(vas therefore 6.7 per cent. The mortality rate for young primiparae "was 
4.6 per cent, for old primiparae 4 per cent, and for multiparae 15.5 per cent. The total 
fetal mortality "was 45 or 21 per cent and for fetus over 2000 gm. -was 12.3 per cent; 
8 died during delivery. 

Convulsions occurred in 67 per cent intrapartum, 27 per cent postpartum, and 6 per 
cent antepartum. Of the 55 postpartum eclampties, 31 -^vere primiparae and 24 multip- 
arae. Of all primiparae 1.29 per cent developed eclampsia and 0.5 per cent of all multip- 
arae. The largest number (34) developed during July, the smallest number (11) dur- 
ing December. Posteclamptic psychoses developed in 8 or 3.8 per cent. 

Of the 151 patients ■\vith antepartum and intrapartum eclampsia 70 delivered spon- 
taneously ■with two deaths, 81 had operative deliveries and 9 died. Of these, 46 were de- 
livered by midforceps, 11 by version and extraction, 8 by craniotomy, 9 by bag induc- 
tion, and 7 by cesarean section. There were 37.6 per cent fetal deaths among the opera- 
tive deliveries and 19.6 per cent among the spontaneous deliveries. A study of the 
cesarean section deliveries in eclampties for the last fifteen years shows no improve- 
ment in maternal or fetal mortality nor in the incidence of postpartum eclampsia over 
those delivered vaginally. Ralph A. Reis. 

King, Gordon: Eclampsia in Chinese Patients, National Med. J. China 16: 653, 

1930. 

The incidence of the disease during the last eight years in the Peiping Union Medical 
College Hospital has been once in 71.4 deliveries, making 33 cases in all. The majority 
of the cases were encountered in the autumn and winter months. Primiparae pre- 
dominated over multiparae in the proportion of 3 to 1. In over 75 per cent of the cases 
no antenatal care had been received. Only in 12 per cent of the cases had regular ante- 
natal care been given, and in this group there was no mortality. 

The distribution of cases was, in round figures, as follows : Antepartum eclampsia : 
60 per cent of cases with an average of 11 convulsions; intrapartum eclampsia: 30 per 
cent of cases with an average of six convulsions ; postpartum eclampsia : 10 per cent of 
cases with an average of four convulsions. 

Definite changes in the fundus oculi are found in most cases of eclampsia. 

Tests for hepatic efficiency, notably the le'vulose tolerance test, give evidence of im- 
paired liver function. Conservative treatment, based upon Stroganoff’s method, is 
favored, cesarean section only used in exceptional cases. There "were 4 maternal deaths 
giving a mortality of 12.1 per cent. The fatal cases all belonged to the antepartum 
group. There was a fetal mortality of 44 per cent. 

Adequate follow-up examinations were possible in 10 cases of the series. Of these 
two went through a subsequent pregnancy normally. Two other patients, however, de- 
veloped chronic nephritis. The real danger of this latter possibility should be borne in 
mind in giving an ultimate prognosis. C. O. Malahd. 

Koteljnikow (Mosco-w): 700 Cases of Eclampsia, J. Akusherstva i. Zonskich 

Boleznej. 42: 196, 1931. 

The material discussed covers the period from 1907 to 1930. In 79,301 deliveries 
there were 684 cases of eclampsia. In 1908 eclampsia occurred in 2.5 per cent of aU de- 
liveries ; 1.2 per cent in the deliveries during 1916, 1.4 per cent during 1918, and 0.2 per 
cent in 1925. Of these 684 cases 87 died. The occurrence of eclampsia varied somewhat 
according to the season of the year, 3.4 per cent in winter, 3.1 per cent in spring, 2.7 per 
cent m autumn, and 2.5 per cent in summer. The maximum number of deaths, 17 per 
cent, occurred in October and the minimum, 1.9 per cent, in July. 



778 


AJIERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


In the pre-war period from 1907 to 1914 there were 306 eclampsia patients in 30,676 
deliveries; from 1915 to 1922, 251 cases in 32,079 deliveries. Eelampsia was found to 
occur five times more frequently in primiparae than in multiparae and there was 2.5 per 
cent of repeated eclampsia. One patient reported had eclampsia during her first de- 
livery and again in her ninth. 

There were 12 eases of eclampsia in the fourth to sixth lunar months and 269 cases 
during the puerperium. Convulsions appeared from six liours to ten days after de- 
livery. Seven patients had eclampsia without convulsions. All of them were operated 
upon. One patient died and the diagnosis was confirmed by the pathologist. 

In this series of 684 cases, 527 (77 per cent) had albuminuria and 62 of them died. 
Blood corpuscles were found in the urine of 63 cases (9.2 per cent), and 22 of these pa- 
tients died. Albumin was absent in 94 cases (13.8 per cent), of this number three died. 
Fatal termination depends not only upon the number of convulsions, but upon their 
strength and the intervals at which they occur. In the material covered by the author 
' convulsions in frequent succession led to death. 

Attention should be called to the fact that the author does not exhibit particular ac- 
curacy in his statistics, also the title number of 700 cases does not correspond with 
the text. Alexandee Gabrielianz. 


Item 


AMERICAN BOARD OP OBSTETRICS AND GYNECOLOGY 

Late applications for certification at the meeting of the Board to be 
held in Milwaukee, Tuesday, June 13, must be made immediately as no 
more applications can he received for this examination after June 2. This 
general, clinical examination by the Board is to be held at The Milwaulcee 
County General Hospital beginning at 9 a.m., June 13, the day before 
the beginning of the scientific session of the American Medical Associa- 
tion. 

AU diplomates and candidates are urged to register early at A. M. A. 
headquarters for attendance on the scientific sessions of the Section on 
Obstetrics, Gynecology and Abdominal Surgery of the American Medical 
Association for which an especially interesting program has been ar- 
ranged. 

Tickets for the dinner and Round Table Conference of the Board to 
be held informally at the Hotel Schroeder, at 7 p.ai. Wednesday, June 14, 
should be obtained at A. M. A. headquarters when registering. All diplo- 
mates, candidates, and any physicians interested in obstetrics and gyne- 
cology may attend by applying for tickets. 

For further information and application blanlts address Dr. P aul Titus, 
Secretary, 1015 Highland Building, Pittsburgh, Pennsylvania. 




Note: Tho Editor accepts no responsibility for the views and statements of 
authors as published in their "Original Communications." 


779 





780 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


tion. Between the original columnar cells and the basement membrane 
is noticed a new layer of low cylindrical cells whose nuclei stain deeply 
with hematoxylin. This double layer of sui’face epithelium occurs in 
discrete places, while normal epithelial conditions prevail in the neigh- 
boring areas. Occasionally, there appears beneath the cervical columnar 
epithelium a new layer of polygonal elements resembling the basal cells 
of the epithelium of the vaginal portion. (Fig. 1.) 

Another specimen obtained at the fourth month (Fig. 2), shows the 
pregnancy changes of the ceiwieal epithelium more advanced. As a con- 
sequence of the rapid proliferation of the surface epithelium, there ap- 
pears a compact aggregation of comparativel 5 ’' small epithelial elements, 
arranged in five to six layers. Tliis new cellular formation stands out 
prominently by its dark color, due to the great affinity to stains of the 



Fig. 1. — Photomicrograph showing reduplication of cervical epithelium in tlie fourtli 

month of pregnancy. X200. 

nuclei which occupy the greater iiart of the cells, while their cj’’stoplasm 
is rather scanty. A distinct, if slight variation in size and shape of 
these cellular elements is readily discernible. Furthermore, the down- 
gTOwth of such structures into the underlying connective tissue may at 
first glance create the impression of beginning tumor formation, passing 
the borderline of malignancy. In spite of the invasiveness of such 
structures, however, the integrity of the basement membrane can be 
definite^ established by using the ditferential stain, e.g., the molybden- 
hematoxjdin technic. Another characteristic feature of the pregnancy 
changes of the cervical epithelium consists in the occurrence of nu- 
merous vacuoles in the structures just described. Within the large 
vacuoles there are visible polymorphonuclear leucocytes, and occasion- 
ally also lymphocytes. Several adjacent vacuoles may coalesce forming 
large, clear spaces which are filled with mucin. 




HOFBAUER ; EPITHELIAL- PROLIFERATION' 


781 


The details of such multilayered formations are clearly demonstrated 
by Fig. 3, taken with higher magnification from a section through the 
cervix of a five months’ pregnant uterus. Attention is drawn to the 
fact that cells of the type of the original ceiwical epithelium are only 



Flpr. 2. — Photomicrograph of cervical epithelium in the fourth month, showing ingrowth 
of the multilayered epithelium. Note formation of large vacuoles. X90. 



Fig. 3 . — Higher magnifleation of part of Pig. 2. showing phenomena in tin- pioliferating 

epithelium. XlTfi. 

visible in the uppermost row, while several layers of cells of the trans- 
itional type have developed beneath them. In places, the latter ele- 
ments ])ush U]i and eventually rejdace the columnar cells. Xumeron.s 






782 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


plasma cells arranged in strands are visible vitbin the core of the 
folds of tbe cervical mucosa. 

Another section obtained from the same nterns iUnstrates the course 



Fig. 4. — Specimen of the fifth month of pregnancy, shoving proliferation of cervical 
epithelium. Note abrupt transition of normal epithelium to actively proliferating 
subepithelial cells vhicli push up the original columnar cells. Note the numerous 
vacuoles vlth lymphocytes and polymorphonuclear leucocytes. X140. 



Fig. 5. — ^Mitosis in newly forming cell layers. XSOO. 


of the developments at both sides of a fold of the cervical mncosa, while 
at the depth of the fold the cervical epithelium has retained its original 
charactei’. It is woi'thj’’ of note that at the right it is apparent that 





HOFBAUER ; EPITHELIAL PROLIFERATION 


783 


there is no basement membrane beneath the cellular hyperplasia, while 
in other places the membrane containing flat elongated cells mth oc- 
casional mitoses can be clearly discerned. The possibility of a confusion 
of such structures with a malignant growth is still enhanced by the 
occurrence in the newly formed layers of mitotic flgures (Fig. 5). 

Similar phenomena of epithelial proliferation occur in the strati- 
fied epithelium of the vaginal portion and within the cervical glands. 
Evidence of the invasive activities of the newly formed cells aris- 
ing from the gland epithelium is obtained by reference to Pig. 6. 
The picture represents the condition of affairs in a cervical gland 
of a uterus removed during the seventh month of pregnancy. In various 
places slender polypoid excrescences protrude into the glandular lumen, 
while beneath the columnar epithelium a massive proliferation of small, 
darkly stained cuboidal cells with ill defined cell boundaries, has taken 



Fig. 6. — Photomicrograph of cervical gland in the seventli month of pregnancy. 
Note invasion of connective tissue by sheets of small dark cells, and the presence 
of vacuoles within this new formation. XIOO. 

place, in which here and there manifestations of mitosis occur. The 
gland appears ensheathed by a conspicuous multilayered aggregate of 
cells which are dipping domi into the connective tissue spaces, the 
basement membrane remaining intact, however. The massive invasion 
of the ceiwical stroma by such tongues of young cells derived from 
the cervical epithelium is demonstrable in several of our specimens. No 
round cell infiltration of the connective tissue as a rc.sponse to, or a 
defense mechanism against that epithelial cell invasion was obseiwed. 
Again, the oecuiTence of large vacuoles in such cell aggregates was 
a constant feature. Of great interest is the presence of decidua-like 
cells in the connective tissue layer adjacent to the proliferating ceiwical 
epithelium, and also the occurrence of occasional mitotic figures in the 
stroma. 



784 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


The epithelial activity of the cervical epithelium during pregnancy 
with a concomitant development of large vacuoles in such structures 
may be conducive to the occurrence of bizarre formations, as repre- 



7. — Bizarre formation In cervical epithelium during: the eigl)th month of pi'eg- 

nancy. X150. 



Pig. S. — Pliotomlcrograph of cervix at term showing the formation of solid cell nests, 
which are dipping down into the connective tissue spaces. XI i 6. 


sented by Pig. 7. In other places multinuclear giant cells are occasion- 
ally visible within the layer of the cervical epithelium. 

At term, the infiltration of the proliferating cervical epithelium into 
the underlying eonneetive tissue quite often results in the foi’mation 
of compact alveoli. The crowding of cells of the transitional type con- 




HOFBAUER : EPITHELIAL PROUPERATION 


785 


taining large liyperchromalic nuclei is evident in tlie periphery of such 
cell nests, while the center shows a tendency toward vacuolization. 
Their boundaries are marked by a well-defined basement membrane. 
Fig. 8 illustrates an example of such a phenomenon. No accumulation 
of Ij^mplioeytes or of round cells is visible in the immediate vieinit}* 



Fig. 9. — Photomicrograph of cervix removed forty weeks after delivery, sliow- 
ing persistence of part of the proliferated epithelium. Note abrupt transition of the 
protruding mass to the normal regenerated cervical epithelium. X200. 



Fig. 10 — Formation of goblet cells in the epithelium of cervical glands at term. 

vacuoles at the case of the epithelium, and the presence of lymphocytes 
witliln the large vacuoles. X175. 


of the structures under consideration, the liyperplasia of the epithelium 
occuiTing witiiout any signs of infiammatory reaction. 

Having become familiar with the extensive cellular activity of the 
cervical epithelium during pregnancy, tiie question sugge.sted itself to 
ascertain for how long a period of time following deliveiy, such struc- 









786 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


tures were recognizable. At present, however, no adequate answer can 
be given. We have been able to trace the persistence of the stractures 
described above to the fortieth week after the termination of preg- 
nancy. Fig. 9 represents the findings in a cervix of a uterus removed 
ten months after delivery. It was of great interest to see that 
the cells of this structure, which was found to project far beimnd the 
level of the neighboring columnar surface epithelium, had retained 
all their characteristics. No indication of any retrograde process is 
visible, the cells apparently having remained in a state of full vitality. 
No indication of undermining of this structure by the epithelium of 
the cervical canal is visible. 

There remains another microseopie finding to which I should like, 
in concluding, to call attention. Among the principal epithelial varia- 
tions encountered in the cervical mucosa of the pregnant uterus, we have 
noticed the formation of vacuoles in the basal portion of the cells. 
These vacuoles occur as the result of the secretion of droplets of cyto- 
plasm which do not coalesce readiljR When such vacuoles in neighbor- 
ing cells enlarge and by i*eason of increasing pressure, their adjacent 
surface membranes break doivn, globules of excessive size form which 
render such specimens of cervical epithelium quite similar to goblet 
cells. Fig. 10 is illustrative of this alteration in the morphology of the 
cervical epithelium. 

COMMENT 

What we desire to place on record in the present communication is 
the evidence of remarkable activity of the epithelium covering the 
cervical canal and its glands during gestation. The data collected by 
routine examination of 29 specimens of gravid uteri reveal a remark- 
able difference in degree of the epithelial alterations. Various evidences 
of epithelial activity, such as reduplication of eeU layers, vacuole forma- 
tion and some vesicular polymorphism of the nuclei were encountered 
in certain areas of every specimen. It was in 8 cases out of the 29, how- 
ever, that verj'' representative activity appeared to be present. In this 
latter group, the principal epithelial variations observed were : epithe- 
lial proliferation with stratification; occurrence of mitotic figures in the 
proliferating epithelium; considerable epithelial doivngrowth into the 
connective tissue; indirect metaplasia; goblet cell formation. 

The mode of origin of the epithelial proliferation is of particular 
interest. In most instances the predominant change consists in the 
formation of a double or treble layer as a clearly visible manifestation 
of the proliferation of the surface epithelium. The transition to the 
single layer may be abrupt, while, on other occasions, gradations 
through a double layer to the treble layer are found. In some places, 
there seems to be evidence that nests of basal squamous epithelium 
which have remained behind the cemdcal columnar cells, have been 



HOPRAUER: EPITHEUAL PROEIPERATION 


stiiTcd into activity and produce polygonal elements, “ infracpithelial 
cells,” -which nndermine and push up the columnar lining. When ep- 
ithelial stratification occui-s and five or more layers become distinguish- 
able, the ejiithelium changes its charaeter and takes on the form of 
cuboidal or transitional cells whose comparatively large nuclei display 
a great aflinity to stains. The ]-)rolifcrating epithelium, with the foima- 
tiou of many layei's, may sometimes supei-ficially resemble a change to- 
ward the squamous type. As an expression of the more or less rapid 
multiplication of the cells, mitotic figures may occur during the various 
months of pregnancy. The formation of several cellular strata fre- 
quently rc.sulls in a distinct invasive character of the epithelium. Oc- 
casionally, the amount of such epithelial downgrowth into the stroma 
may be extreme. Under these conditions, the proliferation may cause 
resemblance to malignant disease. Definite features, however, distin- 
guish it from cancer. In the first place, there is only slight poly- 
moi’phism in the size and type of the cells. What is more important, 
the mitoses are regular and the basement membrane can always be 
made disceniible by appropriate methods. It is well to remember in 
this connection that in the normal cervical mucosa, the basement mem- 
brane is an exceedingly delicate structure, whose demonstration in 
microscopic preparations calls for a special technic. The hematoxylin- 
molybden method may be used for that purpose to great advantage. 
Errol'S in the diagnosis of biopsies obtained from cer\nccs of pregnant 
uteri may occur if the phenomena just detailed arc not borne in mind; 
more particularly since the opinion has been ex]n’essed by experienced 
gjniecologic-pathologists that the presence of mitosis in the cervical 
epithelium should be viewed with the utmost suspicion. ‘‘It is almost 
prima fade evidence of cancer” (Cullen). 

The generation during pregnancy of multilayered cells hy the pro- 
liferating cervical epithelium might he ijroperly designated as epithelial 
hyperplasia, exhibiting certain features of “metaplasia.” 

In casting about for the causative agent of the unique proliferation 
of the cervical epithelium dui’ing gestation, vitamin deficiency was con- 
sidered first as an etiologic factor. Conceimed for some years with the 
effects of withdrawal of certain vitamins from the female organism, the 
studies of Wolbaeh and Howe, Goldblatt and Benischek, Green and 
Mellanby have established Vitamin A and D deficiency a potential fac- 
tor of squamous metaplasia of the columnar epithelium in the respira- 
tory and alimentai'5’- tract, and also to some extent in the urogenital 
system. Certain investigators maintain that Vitamin A deficiency 
may even bear an important causal relationship to cancer develop- 
ment. On the other hand, with the presence of anteiaor pituitary 
hormone in the blood of pregnant -women established and the occur- 
rence of phenomena of proliferation and of metaplasia of the cervical 
epithelium in response to an excess of hormonic principle demon- 



788 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


strated by Hofbaiier and Allen, stimnlation of this epitbelinni by tlie 
hyperactive anterior pituitary during gestation remains the keynote of 
our trend of reasoning. It is appropriate at this junction, however, to 
emphasize our lack of knowledge as to why in certain cases the prolifera- 
tion of the cendcal epithelium is barely noticeable, while in others it 
represents a prominent feature of the cervical structure in the pregnant 
woman. Again, it is well to remember that the occurrence of decidua- 
like connective tissue cells in a certain proportion of the cases under 
consideration likewise attests to enlianced anterior pituitary activity. 
It is also interesting to note the growth activity of the tissues which 
are in immediate contact with the epithelial neoplasia. The occur- 
rence of mitotic figures in the connective tissue elements adjacent to 
the invading cervical epithelium adds a distinct indication of the proc- 
esses of active growth in this locality. With all these facts in mind, 
it is difficult to maintain the explanation offered by Stieve that the 
alterations in the morphology of the cervical epithelium should be 
looked upon as the result of stretching of the epithelium bj^ the fetal 
membranes. 

Now arises the fundamentally important question relative to the 
clinical sig'nificanee of the complex epithelial neoplasia in the ceiwieal 
mucosa of the pregnant woman. The foregoing evidence taken as a 
whole, tends to show that the type of epithelial proliferation described 
represents a condition sui ejenerh. It bears a definite resemblance 
to the moiTDliologic appearance of epithelial neoplasia in the duets 
and acini of cystic mastitis. According to the painstaking studies of 
Cheatle this lesion passes through a series of epithelial events that 
may culminate in carcinoma of the breast. Alterations in the mor- 
phologj’ of the epithelium of the gall Idadder, a near parallel to the 
phenomena seen in the cervix of the pregnant uterus have recently 
been described by King, avIio fully discusses the bearing of such occur- 
rences on the etiology of cancer of that organ. The important studies 
of Schmieden, Ewing and others, showed that in polyposis of the colon, 
in approximately half of the cases, the lesion Avhich at first lacks malig- 
nant attributes may be traced through the various stages of hyperplasia 
to malignant degeneration. Under these conditions, striking stnictural 
changes occur; the rapidly proliferating ejiithelium piling up into 
multilayered buds or projecting into the connective tissue matrix, as 
readily recognizable criteria of the changed morphology. The exact 
relation of such excessive epithelial activity to the onset of malignancy, 
it is tine, remains a mystery; the nature of the agency responsible 
for imparting to cells tbe poAver of disordered groAvtli still being hypo- 
thetical. 

There may sometimes bo great difficulty in distingnishing in various 
organs between blaslomatons gi’OAvth of the epithelium and hyper- 
plasia. The fact remains that cells that haA-e once been stimulated to 



IIOFHAUKU ; 


KFlTIIELlAIi I’KOIAFKHATIOX 


789 


proliferation arc llic most likely later to develop malignancy. In a 
recent illnminating exposition, Oei’tel presents the mechanism of the 
phenomena nncler consideration: “Caneerons growth is preceded hy 
generations of nonly formed cells which still carry the characteristics 
of normal regeneration. Tlu* growth of cancer is in every instance a 
late result of previous tissue cliangcs, which in one instance retains 
the character of pure cell regeneration (cell hyperplasia) and in the 
other is followed hy the creation of ncAV types of cells, atypical in ap- 
pearance and character.” 

In taking up the consideration of the anatomic and histologic changes 
which arc conducive to the occurrence of cancer of the cervix uteri, I 
shall not attempt to make a full summary. The trauma incident to 
childbirth and its after-effects in the cervix, lacerations, eversion, ero- 
sion, and consecpient inflammation resulting in long-continued irrita- 
tion, have been considered as the exciting causes of the disease, 
by most observers. Of late, however, considei'ahle doubt has been 
cast on the correctness or completeness of such reasoning. Martzloff 
writes: “One is confronted by the inesca])able fact that in most in- 
stances cancer of the cervix is definitely associated with a histoiy of 
one or more ]n’cvious pregnancies. Just what actual influence a previous 
pregnancy may have on the cervix uteri to render it particularly sus- 
ceptible to cancer, one cannot satisfactorily answer. Itlost observers 
believe that healed ceiwical lacerations following the inevitable injuiy 
to the cervix at childbirth, miscarriage, or manipulations, supply the 
in'imordium for cervical cancer. There is, however, no definite proof 
at hand to show that cervical cancer begins primarily in an old lacera- 
tion.” Bell, even more tersely, remarks: ‘‘Erosions and lacerations 
of the cervix furnish a theoretical point of origin for cancer, but the 
earliest cancel's we have studied did not arise from these lesions. We 
have no certain knowledge of the inciting causes of cancer of the 
cervix.” In his report on the work of the Cancer Commission of the. 
Ijoague of Nations (1927), Sir George Buchanan states: "Although 
cancer of the cervix uteri is mainly a disease of women who have borne 
children, the work of the Commission has confirmed the conclusion of 
Pellcr and Deelman that it is the fad of a 'pregnancy and not the num- 
ber of deliveries which is the predisposing factor in the production of 
cancer of the uterus.” 

No more conunent is necessary to emphasize further the state of 
confusion and contradiction which prevails in the literature regard- 
ing the etiology of cervical cancer. In the light of the cellular altera- 
tions which occur in the cervical epithelium during gestation, it might 
serve our purpose to focus attention on these physiologic facts as pos- 
sibly relevant to the problem under consideration. This conception, 
however, although intriguing, is still vulnerable. We do not loiow at 
present, how long the hyperplastic cervical epithelium may persist after 



790 


AMERICAN JOURNAIj OP OBSTETRICS AND GYNECOLOGT 


the termination of pregnancy. The difliculties of properly assessing 
and coordinating the findings of epithelial activity in the cei’iacal inn- 
cosa when months or j^ears have elapsed after labor, may be exemplified 
by reference to Fig. 11 which represents an illnstrative example of 
reduplication of the mucosal epithelium in a cervix which had been I'e- 
moved for laceration associated ndth infection, nineteen months after 
deliveiy. There is considerable round cell infiltration in the immediate 
subepithelial zone of the eeiwix. Hence, it is conceivable that as a 
response to the unduly long stimulus of chronic irritation, proliferation 
and increased cellular activity has set in, while the reduplication of 
the cervical epithelium might as well be considered a remnant of the 
gestational processes. Chronic irritation is generally given much prom- 
inence in the discussion of carcinogenetie factoi's, in that it excites eellu- 



Pigr. 11. — Photomicrograph of cervix removed nineteen months after delivery. Note 
reduplication of epithelium of the cervical canal and round cell infiltration beneath it 
(endocervicitis). X200. 

lar proliferation. Yet, befoi’c cancer actually develops, the normal 
relationships and constellations of the tissues break down, due to some 
other unknown factor. It is the change in the character of amj pro- 
liferating epithelium ivhicli has obviously something to do with the 
liability to malignant growth. 

CONCEUSIONS 

The morphologic appearances of the hyperplastic changes of the 
cervical epithelium found in a small but notable proportion of preg- 
nant uteri, with well-defined ingrowths and hyperchromatism, do not 
enable a dogmatic statement to be made upon its significance as a pri- 
mordium of or an antecedent to cervical cancer. No conclusive sequence 
of events from this remarkable epithelial hyperplasia into genuine can- 






IIOrBAUER : EPITHELIAIj PKOEIPERATION 


791 


cer has as yet been observed. Reasoning by analogj^ however, ^vith 
similar phenomena, in the gall bladder, the breast and the alimentarj’’ 
traet on record, I ventnre to suggest that the production during preg- 
nancy of solid tongues of proliferating epithelial cells in discrete places 
of the cervical mucosa, whatever their fate, may represent an impor- 
tant link in the chain of causative factors for the later development of 
malignancy, leaving unanswered the question of the interrelation of 
such epithelial variations and sequential chronic inflammatory condi- 
tions. From these considerations the practical lesson may be drawn 
that as an important element in cancer prophylaxis proper care of 
the endocci’vix in the postnatal clinic requires emphasis on careful 
inspection and immediate attention to any vascular or granular area 
in its substance. 

REFERENCES 

AUcn,E.: .Aiiat. Rec. 55: No. -t, 1933. Palliology, 1930. Clicatlc, G. L. : 

Cancer Review 5: No. 2, 1930; Ann. Surg. 93: 3, 1931; Brit. .1. Surg. 13: 509, 1931. 
Ewing, J.: Neoplastic Discasc.s, 1929. Goidblait and Iscnischch : J. E.^per. Med. 46: 
099, 1927. Green, JI. N., and MeUanhy, E.: Brit. M. J. 2: 091, 1928. Hofbauer, J.: 
Zontralbl. f. Gyniik. 54: 2393, 1930; Centralbl. f. Gynilk. 56: 1020, 1932; 55: 428, 1931; 
Proc. Soc. Explcr. Biol. lilcd. 27: 1011, 1930; Surg. Gynec. Obst. 52: 222, 1931. King, 
E. S. J.: .T. Coll. Surg. Austral. 3: 1930. Marteloff, K. H.: Practice of Surgery 10: 
70. OerteJ, n.: Canadian Med. A. J. 23: 183, 1930. Schmieden, F., and. Westhues, 
K.: Deutsche Ztschr. f. Chir. 202: 1, 1927. Siicve, JI,; Ztschr. f. mikrosk. anatom, 
Porscliung, 11: 1927. Wolbach and JIoxcc: J. Expor. Med. 42: 753, 1925, 


Miiller, H,: Tlie Treatment of Eclampsia, jMonatsclir, f. Geburtsh, u, Gyniik, 87: 

120, 1931, 

Among 30,000 deliveries there wore 200 cases of eclampsia and preeclampsia (0.9 per 
cent). The total maternal mortality was 8.2 per cent but it was 9.3 per cent for the 230 
patients who had convulsions. There were no deaths among the 30 women wdio had pre- 
eclampsia. The fetal death rate among those with eclampsia was 17.7 per cent and 
among those with precclampsia it was 30.0 per cent. Of the 230 eclamptic patients 04 
delivered spontaneously (27.1 per cent). Of the remainder, 113 or 47.8 per cent were 
delivered vaginally and among these were 13 vaginal cesarean sections. Of the 77 
women delivered with forceps 3 died, of the 23 delivered by version 2 died and of the 13 
delivered by craniotomy, 2 perished. Of the 13 women on whom a vaginal cesarean sec- 
tion was performed 6 died. There ■were 45 abdominal cesarean sections in the series 
(19 per cent) and seven motbevs died (15.6 per cent) and seven children were lost. On 
the other hand, of the 191 women treated conservatively 15 mothers died (7.8 per cent) 
and 35 babies perished (18.3 per cent). 

The author concludes from liis study that under similar conditions the modified active 
treatment yields the same results as the purely active therapy. In the most serious cases 
abdominal cesarean section does not help any more than the other methods. 

J. P. Grkenhili,. 



1 

THE TOXIC PSYCHOSES O F PREGNANCY AND THE 

PUBRPERirai*'' 

Leon S. McGoogan, M.D., Omaha, Neb. 

(From the Department of Obstetrics and Gynecology, University of Nebraska Col- 
lege of Medicine) 

S tudents of psychiatry interested in tlie problem of psychoses dur- 
ing pregnanej^ and the puerperinm have definitely established the 
facts that these psychoses, like all other psj’choses, are caused by a 
mnltiplicity of factors; that pregnancy and childbirth may give rise 
to purely functional psychoses that are psychogenically conditioned; 
and that there is no psychosis that is definitely and solely related to the 
phenomena of reproduction. 

The classification by the different psychiatrists of the various types 
that appear is fairly uniform. The three main varieties are: (1) the 
toxic-infectious; (2) the manic depressive; and (3) the schizophrenic, 
yome writers have also included paresis and the psychoueuroses with 
psychotic symptoms. This paper deals only witli the toxic-infectious 
type of psychoses. 

During the fifteen years in which the University Hospital of the Col- 
lege of Medicine of the Univei'sity of Nebraska has been i}i existence, a 
variety of cases of toxic-infectious psychoses during pregnancy and the 
puerperium have been observed. Some of the cases were admitted to 
the neurologic service and some to the obstetric service, but in all cases 
the treatment has been carried out under the supervision of the com- 
bined departments. 

CASE REPORTS 

A. During Pregnancy. — Pour cases of toxic neuronitis ■with a psychosis resembling 
that described by Korsakoff have been observed. These cases have been reported 
by mei in a recent communication and will not be further described here. The 
IJsychosis in these cases is undoidDtedly toxic in origin and in some way related 
to the toxic vomiting which always precedes the onset of the mental and peripheral 
nerve phenomena. As yet the source of this toxin is unknown but it probably 
arises as a result of a metabolic process. Only one of these patients recovered, the 
other three eases terminating fatally. 

Case 5. — University Hospital No. 24002. The patient was admitted the first 
time on Oct. 31, 1927. She was twenty-nine years of age, white, housewife, and 
complained of roaring in the head and the hearing of strange noises. 

The patient was born in Nebraska. She completed the seventh grade at school 
at the age of twelve. She had no j)articular difficulties and got along well ■with her 
classmates at school. She left school because of illness at home, and to help care 
for the familj'. She later worked as a clerk, waitress, cashier, and at other odd 

*Read at the Fourth Annual Meeting of the Central Association of Obstetricians and 
Gynecologists, Memphis, Tenn., September 15-17, 1932. 

792 



MC GOOGAX : 


TOXIC PSYC’UOSKS OF FREGXANCY 


im 


jobs. Her work liod nhva.vs been satisfactor 3 -. Wliilc working as a waitress, tlie 
year prior to her marriage she was shadowed and followed several times by a 
negro. She reimrted this to the jjoliee and was allowed to cariw a gun. A short 
time prior to the onset of her illness u friend told her that this man was in the 
eity in whieh she was then living. Some of her hallueinatioiis were eoncerned with 
the hearing of shots .and voiees e.alling her a negro lover. 

The patient had been married for eight years. The husband and wife were very 

congenial and the sexual life had been entirel.v satisfactorja She had had two 

pregnancies, both were normal, and the last one had terminated two years prior 
to her admittance to the hospital. 

There were never any day dreaming tendencies. The patient had always been 
a good mixer and enjo.ved having people about her. She had never expressed any 
feeling of inferiorit.v, self-depreciation, or ideas of persecution. 

The famil.v history was negative for alcoholism or insanit.y. 

The patient had a]iparentl.v been well until December, ten months prior 

to her entrance, when she had scarlet fever. She was very ill at this time and was 
delirious for four days. From that time on she had hallucinations of an anditor.v 
cliaracter. In ^lay, 1927. she had a spontaneous abortion at the third month of 

gestation and in .Inly conceived again. During the entire summer and up to the 

day of admission the patient continued to have auditory hallucinations. She de- 
veloped insomnia, worried niulnly, and complained of the roaring sensation in 
her head and the hearing of voices mentioned above. She had lost 2.T pounds in 
weight in ten months. 

The physical examination showed considerable loss of weight and except for 
the pelvic examination was entirely negative otherwise. On bimanual examination 
the nterns was found to be about the size of three months’ gestation. 

After one month of pallisitive treatment and failure of the uterus to enlarge and 
of the psychosis to lessen, an evacuation of the uterus was performed, removing 
a fetus, undoubtedly dead for some time, appearing to be slightly under a three 
months’ gestation. 

The patient inijiroved slowly and was dismissed Doc. 17, 1927. She continued 
to improve at home and reg.aincd 10 jiounds of weight. On April 11, 192S, the 
roaring sounds in the head reapjieared and were associated with insomnia and 
auditory' hallucinations. She was readmitted to the hospital April 15, 1928. The 
general physical examination again was negative except for the pelvic findings. The 
uterus was enlarged to about the size of .a three months’ pregnancy. The patient had 
evidently conceived shortl.v after being dismissed from the hospital. 

On April 25, 1928, an abdominal hysterotomy and bilateral salpingotomy was 
performed. She made an excellent recovery from the operative procedure and was 
dismissed on May 5, 1928, with all hallucinations absent and without any other 
phenomena of her psychosis. She had an excellent insight into her condition. 

Diagnoxl’i: Schizophrenic reaction with delirious features. 

B. During the Pucrparium . — Case 1. — This case like the first four cases reported 
above was a case of Korsakoff ’s psychosis and occurred following a therapeutic 
abortion for pernicious vomiting. It has also been previously' reyrorted.! 

Case 2. — University' Hospital Ko. 280G4. The patient was admitted on March 
24, 1929, on the eighth day after delivery. She was white, twenty-six years of age, 
and married. 

The family history' was negative. 

The patient had been born in Nebraska, and was one of a family of eight chil- 
dren. She finished the eighth grade of school and made good grades by hard studv. 
Sho stopped school to nurse her mother who was seriously and chronicallv ill. She 



794 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


later began a preparatory course at a normal sebool but was forced to quit because 
of nervousness brought about by study and working in a home for her board. 

When she was twenty-two years of age she worked in a physician’s office. Dur- 
ing the following year she had a very serious love affair which was terminated by 
the sudden death of the young man. Subsequently she married at twenty-five and 
her husband stated that the marriage had been a perfectly happy one. He and 
her mother both agreed that the patient was not unduly sensitive, that she made 
social contacts easily and had no day dreaming tendencies. 

The patient became pregnant during the second year of her marriage. The preg- 
nancy was entirely uneventful and on March 5, 1929, she delivered her child after 
a ten-hour labor. The puerperium was entirely normal until the eighth day. On 
the evening of the seventh day the husband of another patient in the ward came 
to see his wife. That night the patient dreamed that this man had stolen her baby. 
The next da 3 ' she was irrational. She was certain that her baby^ had been stolen 
and told her husband that he should have stayed at the hospital during the night, 
like the other husband. 

She was admitted to the University Hospital, presenting great psychomotor ac- 
tivity and begging her husband to take her home. She talked and sang inces- 
santly. There were flights of ideas but they centered about her family, particularly 
her husband and child. She also had hallucinations of an auditory and visual 
nature. 

On admission the general physical examination was entirely negative. 

The temperature was 100.6° The urine was normal. The blood Wasser- 
mann reaction was negative. The blood hemoglobin was 90 per cent (Sahli), the 
erythrocytes 5,440,000, and the leucocytes were 12,200 per c. mm. A differential 
count showed 72 per cent polymorphonuclear cells. 

The patient was in the hospital one month during which time she showed little 
or no improvement. She was dismissed against advice to go to her home. 

The patient on Aug. 10, 1932, reported that she did not fully recover until one 
year after her dismissal, but during the past year she has been in good health. 
There have been no other pregnancies. 

Biaffnosis: Manic reaction with delirious features of hallucinosis. 

Case 3. — University Hospital No. 7741. Patient, white, thirty-three years of age, 
was admitted to the hospital March 3, 1922, in labor. The present pregnancy, the 
sixth, had been normal throughout as had the previous pregnancies. 

Labor was uncomplicated, and she delivered herself spontaneously of a normal 
male child. The puerperium was uneventful until March 6, on which day she com- 
plained of severe lower abdominal pain and headache. A general physical exam- 
ination was negative except for considerable tenderness over the uterus. Temper- 
ature 104.2° F., and pulse 140. Leucocyte count, 14,800, 88 per cent polymorphonu- 
clears. The urine examination was essentially negative. The patient’s sjTnptoms 
continued and there also developed some pain in the lower back. On March 11 she 
passed a small blood clot and on March 12 she passed about 400 c.c. of old clotted 
blood and some shreds of fetal membranes. She then had a severe generalized 
chill following which she became markedly disoriented. An examination of the 
urine on that day showed the presence of a small amount of albumin and many 
hyaline casts, leucocytes, and a few red blood cells. During the next two weeks the 
patient continued to have chills and fever and marked mental confusion and dis- 
orientation, The uterus slowly involuted and the urine continued to contain large 
numbers of pus cells. The patient was removed from the hospital against advice 
on March 26 only slightly improved, but subsequently made a complete recovery. 

Diagnosis: Pregnancy, subinvolution, pyelitis, toxic psychosis. 



MCGOOGAN; TOXIC PSYCHOSES OP PREGNANCY 795 

Case 4. — ^University Hospital No. 25812. Patient, -white, twenty-seven years of 
age, a tertigr.avida, was admitted June 25, 1928. 

Last regular menses Nov. 30, 1927. The pregnancy had heen entirely unevent- 
ful until June 21, 1928, at which time she noticed some soreness in the throat 
upon .swallowing; and fullness in the epigastrium upon taking food. She took no 
food therefore except milk. On the day prior to admission she became nauseated 
and vomited; at one time the voniitus contained some bright red blood. She went 
into labor on Juno 27 and after a short labor was delivered of a seven-month pre- 
mature stillborn female child. During the delivery the patient was very excited and 
claimed she had a confession to make. The nature of this “confession” was 
never learned as the patient disclaimed all knowledge of it later. 

Following the delivery the patient continued to have difficulty in swallowing, 
and continued to be nauseated and to vomit. On the evening of June 30 the 
patient became irrational with auditory and visual hallucinations. On the next 
day the temperature was 103° and tho pulso 130. A white blood count showed 
13,000 leucocytes. On July 3 tho mental confusion had entirely disappeared and the 
temperature was 100°. The general physical examination during this period had 
been entirely neg.ativc except for a continued subinvolution of tho uterus -ndth 
some pain over the uterus upon deep palpation. The lochia which had been 
scanty liad a very foul odor. 

Tho patient rapidly improved, tho temperature became normal, the uterus in- 
voluted and the patient was dismissed on July 7. 

Diagnosis: Pregnancy, premature labor, stillborn fetus, sapremia, toxic psy- 
chosis. 

Case 5. — University Hospital No. 31729. Patient, a seexmdipara, aged twenty- 
nine, was admitted on ^fay 2, 1930. Her maternal grandmother and one maternal 
aunt had sufTered from a puerperal psychosis. 

The patient’s pregnancy had been entirely normal and she had delivered her- 
self ten days prior to entrance to the hospital without difficulty. The puerperium 
was entirely uneventful until the fourth day, at which time the patient developed 
great psyehomotor activity and auditory and visual hallucinations. 

On admission physical examination was negative except for tho pelvic findings. 
The fundus uteri reached about halfway to the umbilicus. There was a very 
foul smelling, dark red colored vaginal discharge. The temperature was 100° and 
pulso 88. The blood showed 14,000 leucocytes with 85 per cent polymorphonuclear 
cells. 

The temperature slowly subsided, the uterine infection slowly lessened and the 
mental phenomena gradually disappeared. 

The patient was dismissed on July 7, 1930, apparently fully recovered and -with 
a good insight into her condition. 

Diagnosis: Pregnancy, uterine infection, toxic psychosis. 

Case 6 . — ^University' Hospital No. 34267. Patient, a priniigravida, nineteen 
J'cars of age, was admitted on Feb. 7, 1931. Last regular menses commenced on 
May 7, 1930. The pregnancy had been entirely normal until February 5, when 
the patient had a generalized convulsion following which she developed considerable 
edema of the hands, face, and feet. She had four more convulsions and was ad- 
mitted to the hospital in a semieomatose condition. There was marked peripheral 
edema; the blood pressure was 160/100 and the urine contained 2.5 gm. of albumin 
per liter. The StroganofC course of treatment for eclampsia was carried out for 
twenty-four hours and at the end of this period she seemed to be somewhat worse. 
A classical cesarean section was done and a living female child delivered. 

The patient improved following tho delivery, the blood pressure became lower, 
the mental torpor disappeared, but the edema persisted. On February 11 the 



794 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


later began a preparatory course at a normal school but was forced to quit because 
of nervousness brought about by study and working in a home for her board. 

When she was twenty -two years of age she worked in a physician's office. Dur- 
ing the following year she had a very serious love affair which was terminated by 
the sudden death of the young man. Subsequently she married at twenty-five and 
her husband stated that the marriage had been a perfectly happy one. He and 
her mother both agreed that the patient was not unduly sensitive, that she made 
social contacts easily and had no day dreaming tendencies. 

The patient became pregnant during the second year of her marriage. The preg- 
nancy was entirely uneventful and on March 5, 1929, she delivered her child after 
a ten-hour labor. The puerperium was entirely normal until the eighth day. On 
the evening of the seventh day the husband of another patient in the ward came 
to see his wife. That night the patient dreamed that this man had stolen her baby. 
The next day she was irrational. She was certain that her baby had been stolen 
and told her husband that he should have stayed at the hospital during the night, 
like the other husband. 

She was admitted to the University Hospital, presenting great psychomotor ac- 
tivity and begging her husband to take her home. She talked and sang inces- 
santly. There were flights of ideas but they centered about her family, particularly 
her husband and child. She also had hallucinations of an auditory and visual 
nature. 

On admission the general physical examination was entirely negative. 

The temperature was 100.6° The urine was normal. The blood Wasser- 
mann reaction was negative. The blood hemoglobin was 90 per cent (Sahli), the 
erythrocytes 5,440,000, and the leucocytes were 12,200 per c. mm. A differential 
count showed 72 per cent polymorphonuclear cells. 

The patient was in the hospital one month during which time she showed little 
or no improvement. She was dismissed against advice to go to her home. 

The patient on Aug. 10, 1932, reported that she did not fully recover until one 
year after her dismissal, but during the past year she has been in good health. 
There have been no other pregnancies. 

Diagnosis: Manic reaction with delirious features of hallucinosis. 

Case 3. — University Hospital No. 7741. Patient, white, thirty-three years of age, 
was admitted to the hospital March 3, 1922, in labor. The present- pregnancy, the 
sixth, had been normal throughout as had the previous pregnancies. 

Labor was uncomplicated, and she delivered herself spontaneously of a normal 
male child. Tlie puerperium was uneventful until March 6, on which day she com- 
plained of severe lower abdominal pain and headache. A general physical exam- 
ination was negative except for considerable tenderness over the uterus. Temper- 
ature 104.2° P., and pulse 140. Leucocyte count, 14,800, 88 per cent polymorphonu- 
clears. The urine examination was essentially negative. The patient’s symptoms 
continued and there also developed some pain in the lower back. On March 11 she 
passed a small blood clot and on March 12 she passed about 400 c.c. of old clotted 
blood and some shreds of fetal membranes. She then had a severe generalized 
chill following wliich she became markedly disoriented. An examination of the 
urine on that day showed the presence of a small amount of albumin and many 
hyaline casts, leucocytes, and a few red blood cells. During the next two weeks the 
patient continued to have chills and fever and marked mental confusion and dis- 
orientation. The uterus slowly involuted and the urine continued to contain large 
numbers of pus cells. The patient was removed from the hospital against advice 
on March 26 only slightly improved, but subsequently made a complete recovery. 

Diagnosis : Pregnancy, subinvolution, pyelitis, toxic psychosis. 



MCGOOGAN; TOXIC PSYCHOSKS OF PREGNANCY 795 

Case 4— ■University- Uospital No. 25S12. Patient, wliito, twenty-seven years of 
age, a tertigravida, was admitted June 25, 1928. 

Last regular menses Nov. 30, 1927. The pregnancy had been entirely unevent- 
ful until Juno 21, 1928, at which time she noticed some soreness in the throat 
upon swallowing; and fullness in the epigastrium upon taking food. She took no 
food therefore except milk. On the day prior to admission she became nauseated 
and vomited; at one time the vomitus contained some bright red blood. She went 
into labor on Juno 27 and after a short labor was delivered of a seven-month pre- 
mature stillborn female child. During the delivery the p.aticnt was very excited and 
claimed she had a confession to make. The nature of this ‘ ‘ confession ’ ’ was 
never learned as the patient disclaimed all knowledge of it later. 

Following the delivery the patient continued to have difficulty in swallowing, 
and continued to be nauseated and to vomit. On the evening of June 30 the 
patient became irrational with auditory and visual hallucinations. On the next 
day the temperature was 103° and the pulse 130. A white blood count showed 
13,000 leucocytes. On July 3 the mental confusion had entirely disappeared and the 
temperature was 100°. The general physical examination during this period had 
been entirely neg.ative except for a continued snbinvolution of tho uterus with 
some pain over the uterus upon deep palpation. Tho loehia which had been 
scanty had a very foul odor. 

Tho patient rapidly improved, the temperature became normal, the uterus in- 
voluted and the patient was dismissed on .Tuly 7. 

Diagnosis; Pregnancy, premature labor, stillborn fetus, sapremia, toxic psy- 
chosis. 

Case 5. — University Hospital No. 31729. Patient, a secundipara, aged twenty- 
nine, was admitted on ^fay 2, 1930. Her maternal grandmother and one maternal 
aunt had sufTcred from a puerperal psychosis. 

Tlio patient’s pregnancy had been entirely normal and she had delivered her- 
self ten daj-s prior to entrance to the hospital without difficulty. Tho puerperium 
was entirely uneventful until the fourth day, at which time the patient developed 
great ps 3 -ehomolor activity and auditorj- and visual hallucinations. 

On admission phj-sical examination was negative except for tho jielvic findings. 
Tlic fundus uteri reached about halfwaj- to tho umbilicus. There was a verj- 
foul smelling, dark red colored vaginal discharge. Tho temperature was 100° and 
pulse 88. The blood showed 14,000 leucocytes with 85 per cent polymorphonuclear 
cells. 

The temperature slowl.v subsided, the uterine infection slowlj- les.sened and the 
mental phenomena graduallj- disappeared. 

The patient was dismissed on Julj- 7, 1930, apparently full}- recovered and ivith 
a good insight into her condition. 

Diagnosis: Pregnancy, uterine infection, toxic psychosis. 

Case 6 . — ^University Hospital No. 342G7. Patient, a primigravida, nineteen 
years of age, was admitted on Feb. 7, 1931. Last regular menses commenced on 
^fay 7, 1930. Tho pregnancy had been entirely normal until February 5, when 
the patient had a generalized convulsion following which she developed considerable 
edema of tho hands, face, and feet. She had four more convulsions and was ad- 
mitted to the hospital in a semicomatose condition. There was marked peripheral 
edema; tho blood pressure was 160/100 and the urine contained 2.5 gm. of albumin 
per liter. The Stroganoff course of treatment for eclampsia w-as carried out for 

wenty.four hours and at the end of this period she seemed to be somewhat worse. 

c assical cesarean section was done and a living female child delivered. 

The patient improved following tho delivery, the blood pressure became lower, 

le mental torpor disappeared, but the edema persisted. On February 11 the 



796 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


temperature U'liich had been normal rose to 102° (rectal) and on the following 
day the patient became irrational with delusions and hallucinations. The lochia 
was foul smelling and the abdominal wound clean. The temperature reaction con- 
tinued reaching 104° on February 17 on wliieh day a leucocyte count showed 
12,800 cells. An abscess of the right vulvovaginal gland developed and drained 
spontaneously on February 22, following which the temperature slowly abated and 
the mental symptoms disappeared. The patient was dismissed from the hospital 
March 7, 1931, in excellent condition. 

Diagnosis: Pregnancy, eclampsia, sapreinia, vulvovaginal abscess, toxic psychosis. 

Case 7. — University Hospital No. 37101. Patient, a tertigravida, white, twenty- 
eight years of age, was admitted on Nov. 26, 1931, at term but not in labor. On 
December 11, 1931, a medical induction of labor combined with artificial rupture 
of the membranes was done, and the patient delivered herself spontaneously of a 
normal male child. On the following day the temperature was 104.2° and there 
was some tenderness over the uterus. On December 15 the patient develo]Ded 
auditory and visual hallucinations with ideas of persecution. The hemoglobin was 
80 per cent (Sahli), erythrocytes 5,400,000, and the leucocj-tes 13,000, with 75 
per cent polymorphonuelears. The temjrerature slowly abated but suddenly reached 
103° on December 21. On December 22, blood showed 24,400 leucocytes with 
90 per cent polymorphonuelears. A general physical examination of the patient 
revealed only a subinvolution of the uterus which was slightly tender. The lochia 
was profuse and had a very foul odor. 

The symptoms slowly disapiieared, and on Jan. 27, 1932, the patient was 
apparently fully recovered. On that day a perineorrhaphy and bihiteral salpingot- 
omy were performed. The patient had a recurrence of her mental symiitoms 
twenty-four hours after the operation, but in a much milder form. She made, 
however, a fairly rapid recovery and was dismissed from the hospital on Feb. 19, 
1932. 

Diagnosis; Pregnancy, sapreinia, toxic psychosis, with recurrence postoperative. 

Case 8. — University Hospital No. 37765. Patient, a secundigravida, white, 
American, twenty-eight years of age, was admitted on Jan. 30, 1932, in labor. 

She had her first child in 1930. She did not menstruate at all following the 
delivery but conceived the second time some time in April of 1931. A short time 
later the husband was sentenced to the state prison for theft, this being his third 
offence of such a character. The patient tried to keep this knowledge from her 
family and attempted to continue working in the packing plant to support herself. 
She lived with her husband’s family and to them never seemed morose or de- 
spondent although the dispensarj- staff noticed that she seemed unusually reserved 
and slightly morose. The patient was moderately alcoholic. 

During the deliverj- the patient was very uncooperative. The puerperium was 
uneventful until Februarj- 6 when she accused the nurses of having burned her 
baby and threatening her with bodily harm. The following daj^ the temperature 
was 100,5°, and it reached its peak of 102° on Februarj’ 8. The leucocyte count 
was only 9,800 with only 58 per cent polymorphonuclear cells. Slight tenderness 
over a slightly subinvoluted uterus. 

The temperature slowly subsided, the lochia became very malodorous and the 
mental disorientation disappeared on February 15, The patient was dismissed 
on March 2, 1932. 

Diagnosis: Pregnancy, intrauterine infection, toxic psychosis. 



MC GOOGAK : TOXIC PSYCHOSES OP PREGNANCY 


797 


ETIOLOGY 


(a) Hereditary factors. A familial history of mental aberrations is 
present in only one instance. Ellery^ emphasizes the fact that in all 
of the psychoses associated with puerperium there is an inability to 
satisfactorily interview the members of the family becanse of the ‘ ‘ false 
sense of shame which many still attach to familial insanity, keeping 
their psychotic skeletons in the cupboard of secrecy. ’ ’ 

(b) Health, jirevions, during and following gestation. As in all 
types of psychoses the patient’s health is an important factor. The 
presence of infections diseases, anemias, menstrual disturbances, rapidly 
repeated pregnancies or toxemia may be the exogenous factor of ex- 
haustion or toxemia which leads to the mental breakdown. In 5 of the 
patients there was an associated pernicious vomiting. In one ease there 
was a missed abortion followed by two rapidly repeated gestations. In 
7 cases there was a postpartum infection. Pyelitis was present in one 
case, intrauterine infection in 5 eases and eclampsia with vulvovaginal 
abscess and intrauterine infection in the remaining case. 

The mental adjustment of the patient to her pregnancy and her social 
and economic environment is as important as her physical health. Fears 
and worries lay the groundwork for physical ill health and mental 
aberration. 


(c) Personal make-up. The personality pattern of the individual is 
of extreme importance. A normal stable individual with febrile toxemia 
may show no delirium while the psychopathic type with the same in- 
toxication will show a toxic psychotic reaction. 

Parity . — ^Multiparas are apparently more subject to the development 
of a toxic psychosis than are primiparas. Pour of the 13 patients were 
primiparas and 9 were multiparas. Rapidly repeated pregnancies with 
their resultant morbidity and exhaustion may in some cases as in Case 
5 of the iiitranatal group play a most important role. 


Frequency. — Zilboorg® in a tabulation of reports covering 10,000 cases 
of psychotic women showed that 8.7 per cent belong to the pregnancy 
group. Various reports from institutions of psychiatry have showm 
that the toxic infectious group of psychoses constituted 32 per cent,* 
36 per cent,® 34 per cent,® and 48 per cent,- respectively. Because the 
figures are so nearly similar for institutions of psychiatry these per- 
centages are undoubtedly correct. On the other hand they do not give 
tile true frequency, because there are no doubt many eases which are so 
short of duration or so light in character that they do not require institu- 
tional care. The actual frequency therefore must be somewdmt greater. 
There are no available reports from any of the large obstetric hospitals 
or clinics on this subject. 



798 


AMERICAN JOURNAL. OP OBSTETRICS AND GYNECOLOGY 


Period of I'licubation . — There is no definite period of incubation; the 
severity of the precipitating factor and the resistance of the brain deter- 
mine the onset. In Streeker’s® series of cases which were all puerperal 
and all institutional, the average number of daj'^s from the date of de- 
livery to the day of the onset of the psychosis was 22, In the present 
small series of puerperal cases the average number of days was seven. 

Symptoms and Diagnosis . — ^Alterations in the sensorium are distin- 
guishing features of the toxic delirious reaction. In cases due to in- 
fection the presence of a rise in temperature, leucocytosis, and other 
signs of infection are aids in the diagnosis, while in pure toxemic 
cases, the plij’^sical and laboratory signs are guides. One must of course 
exclude the other types of ps 3 ’^choses, and tlie diiferential diagnosis is 
well discussed by Streeker® and Zilboorg.’’’ ® 

Treatment . — Prior to delivery the obstetric care per se is to be carried 
out as is indicated by the physical signs. Whether or not to emptj'^ the 
uterus will have to be determined in each individual case. It is gen- 
erallj'’ believed that in those eases of hj^peremesis gravidarum which 
develop peripheral neuritis and a ps,vchosis therapeutic abortion is of no 
avail. In those cases in which the fetus has died in utero, there is of 
course no question as to the advisabilitj’- of emptying the uterus. 

During the pregnancj’’ and the puerperium the psychosis should be 
treated as any other toxic psychosis Avith absolute rest and quiet, copious 
elimination, mild sedation, and elimination and treatment of the causa- 
tive factor. 

Higgins® in 1914 pointed out that when the psj^chiatrist sees the patient 
the damage has been done and that it is the duty of tlie obstetrician 
and general practitioner to carefully study each patient, as to her in- 
heritance, her past history, and her reactions to her pregnancjL He 
should be on guard for the appearance of the early signs of an impend- 
ing mental breal?:. Too many times in the past the obstetrician has 
lightly passed over or entirelj>' disregarded the early symptoms, been 
confounded at the outbreak of a psychosis, and then disclaimed any 
responsibility for its occurrence. It is as important to be acquainted 
with the earlj’- indications of an impending psj'^chosis as it is to be versed 
in the eailj'- signs and symptoms of a toxemia of pregnanejL 

Streckero strongly emphasizes the fact that “much of the therapeutics of the 
psychoses of the puerperhmi is embodied in the prevention which will result when 
serious attention is given to the mental needs of the pregnant woman. ’ ’ He rightly 
claims that “it is as much a part of the duty of the . . . practitioner to 
modify or resolve these difficult situations (i.e., misconceptions of childbirth, ap- 
prehension, worry, family misunderstandings, loss of beauty, etc.) as it is to have 
the urine tested.” 


Women with, knomi psychotic tendencies, or those who are physically 
below par, or who develop an intereurrent infection or a toxemia of 



MCGOOGAN: TOXIC PSYCHOSES OP PREGNANCY 


T99 


pregnancy should be carefully •watched. Any symptom such as in- 
somnia, prolonged anxiety, physical or mental exhaustion, or change of 
character should arouse suspicion of an impending psychosis and treat- 
ment should he instituted. 

Women who have had and suffered from a previous attack of toxic 
infectious psychosis should he urged not to attempt another pregnancy. 
Even as a contracted pelvis and general systemic diseases make a •woman 
ineligible for pregnancy if she wished to enter it with impunity, so 
should mental disease even though the phenomenon is less apparent and 
tangible. The practitioner and specialist must as Ellery has stated 
“give enlightenment to the ignorant, and sage counsel to those whose 
erring impulses may be leading them along the pathways of misery.” 

Prognosis . — The course of the disease varies from a few days or several 
weeks to several years or even to permanent dementia. In the Korsakoff 
type associated with hyperemesis gravidarum, the prognosis is poor as 
to life and as to ultimate recovery’^; 80 per cent of our patients died. 
Of the remaining eases, due to other causes all recovered. Streeker 
reports 76 per cent recovery and Ellery 49 per cent recovery, and 18 
and 33 per cent respectively of their patients were permanently de- 
mented, while the remainder terminated fatally. 

The condition may recur during a subsequent pregnancy as is sho^wn 
in Case 5 of the intranatal group. 


SUMMARY 


1. Thirteen cases of toxic psychoses during pregnancy and the puer- 
perium are presented with an effort to point out etiologic factors. 

2. Familial insanity, the individual’s personality pattern, and her 
previous or present medical or obstetric morbidity are most important. 

3. There are no available reports as to the actual frequency of this 
complication. 

4. More attention must be given to the mental needs of all women 
entering pregnancy. 

5. The obstetrician must familiarize himself into the underlying 
factors of a psychosis, and recognize the early signs and sjunptoms in 
order to institute prophylactic treatment. 


of express his thanks to Hr. A. E. Bennett of the Hepartment 

Neuropsychiatry who gave many valuable suggestions during the 
iJreparation of this paper. 


REFERENCES 

(1) McGoogan, L. S.; Jour.-Laneet 52: 735, 1932. (2) Ellery, E. S.: Med. 

Zilboorg, G.: Am. J. Obst. So Gynec. 15: 145, 1928. 
Kuyatrick, E., and Tiehout, E. M.: Am. J. Psych. 6: 145, 1926-7. (S') 

IF. Cw J. Kans. Med. Soc. 31; 191, 1930. (6) Streeker, E. H., and 

^‘Omgh, E. G.: Arch. Neurol. & Psychiat. 15: 293, 1926. (7) Zilboorg, G.; Am. 

Idem: Am. J. Psych. 2: 733, 1929. (9) 

5''" •^“' 244, 1914. Other references not quoted: 

^^29. DeLee, J. B.: Principles and Prac- 
tice of Obstetrics, ed. 5, Philadelphia, 1930, W. B. Saunders Co., p. 115 . 

420 SOCTH TtVENTT-riFTH AVENTJE. 



I 

ETIOLOGY OP j^ROLAPSE> 

Erwin von Gbapf, M.D., Iowa City, Iowa 

(From the Departme-nt of Ohstetrics and Gynecology, State University of Iowa) 

/^BSTETRIC traumas, ineludmg lacerations of the soft parts, over- 
distention of the miiseular, fascial, and ligamentous “fixation 
apparatus” of the vagina and uterus, are commonly looked upon as 
paramount in the development of uterine descensus and prolapse. In 
addition, great importance has been attributed to retrodeviation of the 
uterus as a predisposing factor. 

The serious study of procidentia was undertaken many years ago for 
the purpose of correlating changes in tlie tissues and in the local 
anatomical topography with the actual conditions which finally lead to 
the development of prolapse. 

Martin, in Berlin, emiihasized the fascial and ligamentous apparatus 
as the chief factor in the normal topography of the female genitalia, 
while Tandler and Halban held the opinion that the muscular pelvic 
floor was more important. Credit should be given to E. Wertheim, who 
spent more than twenty years in the development of the operative 
treatment of prolapse, for first recognizing and pointing out, more than 
anj' other author, that the muscular floor and the connective tissue are 
of equal importance. The work of these men, and that of T. J. Watkins, 
in this eountrjq covers all the necessary anatomical information, and 
has been fundamental in the development of the various successful 
methods of operative repair, but lias not disclosed the etiology of pro- 
lapse. 

It must be admitted that usually, but not always, prolapse is found 
in women -who have had at least one child; but I have felt for many 
years, that “birth trauma” and movable retroflexion of the uterus do 
not alone determine the development of prolapse. Two women, who 
as frail, slender girls, have lived and grown up under the same environ- 
ment, may become pregnant and have normal deliveries. The one 
“blossoms out” following parturition and becomes a fully efficient and 
healthy mother and woman; the other remains Aveak, never overcoming 
the strain of childbirth, and soon develops enteroptosis and prolapse. 
This entirely different behaAUor is an expression of Amrjdng ability to 
respond to the same physiologic event, of an inherent “constitution,” 
definitely determined for each individual at the moment of fusion of 
its parental germinal cells. 

*Read at the Fourth Annual Meeting^ of the Central Association of Obstetricians and ■ 
Gynecologists. Memphis, Tenn., September 15-17. 1932. 


SOO 



VON GHAFF: ETIOLOGY OF PROLAPSE 


801 


That delivery acts merely as an initiating factor, favoring the de- 
velopment of descensus and prolapse, is evidenced by many women who 
do not show the slightest derangement following ten or more deliveries; 
while, on the other extreme, nnlliparons women, even virgins, occasionally 
develop varicosities, feeling of “bearing down,” and marked degrees 
of prolapse. 

Whether or not prolapse develops is primarily dependent upon the 
individual constitutional disposition, i.e., npon the functional efficiency 
or inefficiency of the mesodermal structures, such as connective tissue, 
fascia, and muscle. Stiller and P. Mathes first recognized that group 
of women with all the characteristics of congenital weakness and loose- 




1- — "Pyknika,” the ideal type for reproduction. E, “Astlienico-ptotic” type. 

(Mathes.) 

ness of the mesodermal tissues, who are more likely to pay for mother- 
hood with procidentia, and desigmated them as the “asthenico-ptotic” 
type. 

In very marked cases, this type of 'woman may easily be recognized 
On first sight (Pig. IB). The shoulders are sloping, the thorax flat, the 
I’lbs join the vertebrae at acute angles, the abdominal wall is lax and 
protrudes below the umbilicus, being unable to resist the pressure of the 
enteroptotie viscera. The facial expression is often shy, anxious, and 
loournful, while the psychic condition is characterized by “lack of 
pep,” poor self-control, and lability, -with sudden changes of temper 
from unnatural vivacity to melancholia. In addition to this fully de- 
veloped type, there are many minor degrees of asthenico-ptotic con- 



802 


AMERICAN JOURNAL, OP OBSTETRICS AND GYNECOLOGY 


stitution, which are concealed under perfectly normal appearance, and 
can he recognized only by the discovery of enteroptosis, movable retro- 
flexion of the uterus, varicose veins of the lower extremities, and labile 
temperament. 

It is interesting, as evidence of a changing concept of female beauty, 
to note that at the time of primitive Christian art under the old Roman 
Empire and at the height of the Italian Renaissance in the fifteenth 
century, the ideal type of woman approached that which we designate 
as asthenieo-ptotie, and which is now recognized as poorly adapted to 
childbearing. 

Besides the asthenieo-ptotie constitution, we find that the intersexual, 
virile woman, the boyish, frail, and slender girl, as well as the acro- 
megalic, masculine woman, is less apt to fulfill the demands of reproduc- 
tion without lasting damage, although they may often be otherwise 
outstanding in their intellectual capacities and most desirable com- 
panions in marital life. As a third predisposing factor, constitutional 
endocrine disturbances may be mentioned, although as yet they are little 
understood. 

Finally, localized reduction of the strength of the muscular support 
of the pelvic floor incident to an occult spina bifida, must be considered 
in every prolapse occurring in a nulliparous woman. 

The genuine, primitive, pure woman knomi as the “pylcnik” type has 
far the best chance to tolerate even a large number of deliveries with 
perfect involution and restitution of the genitalia. 

If it is true that the development of prolapse depends upon individual 
constitution, we may expect to find, according to the different func- 
tional efficiency of the structures derived from the mesodermal tissue, 
four groups of women suffering from prolapse. 

1. Virgins and nnllipaious women with prolapse, often stigmatized by: occult 
spina bifida, varicose veins, enteroptosis, movable retroflexion of the uterus, 
asthenieo-ptotie or virile intersexual appearance, or endocrine obesity. 

2. Women who have developed prolapse soon after the first delivery may also 
show the above stigmas. These two groups include individuals with definitely in- 
efficient connective tissue, and a constitutional inferiority with regard to repro- 
duction. 

3. Women in whom symptoms of prolapse have appeared, often many years 
after the last delivery, at the climaoteric age (by far the largest group). All these 
women have a moderate degree of tissue weakness which becomes manifest only 
by the additional loss of elasticity of the connective tissue, appearing at the time 
of physiologic involution (climacteric age). 

4. A comparatively small group of women whose prolapse has developed only 
after the menopause. As they went undisturbed through the climacterium, their 
tissue function may be considered as almost normaL 

In ordex’ to support this conception by statistics, over a considerable 
period of time, all new patients were carefully examined, paying especial 
attention to the condition of the pelvic outlet, recording even the 



VON GEAFP: ETIOLOGY OF PROLAPSE 


803 


slightest degree of relaxation. In this way, 800 women, each of whom 
has had at least one child, have been reviewed. Besides, 26 nulliparous 
women were seen, with more-or-less marked relaxation and prolapse.^*"' 


I. PROLAPSE IN NULLIPAROUS WOMEN 

The 26 women of this group varied in age from seventeen to sixty- 
nine years. More than half of them, however, were over thirty-six years 
of age. This shows again that in an individual witb constitutionally 
poor tone of the connective tissue, the additional physiologic relaxation 
which comes wdth advanced years, is likely to favor the development 
of descensus, regardless of whether or not the woman has home a child. 

Most of the patients had no subjective symptoms, and the relaxation 
was merely an accidental finding. Eight of these women, however, had 
come to the clinic because of a “bearing down feeling” or the sensation 
of a foreign body in the introitus, and backache; in seven of them, 
operation was found necessary. Pour are of especial interest, because 
occult spina bifida was suspected, and x-ray pictures of the sacrum were 
taken. In two cases the x-ray pictures were distinctly positive (Cases 
1 and 3), in one case suspicious (Case 4), and in one case negative. 


Case 1.— J. K., aged twenty-four years, white, married for six years, no preg- 
nancies, believed to have been operated upon immediately after birth for anal 
atresia. Has never been seriously sick. Menstruation normal. At sixteen years, 
obstinate constipation and a feeling of “bearing do\vn” with frequent micturition 
were noted. Examination showed an almost complete prolapse of the vagina with 
enormous elongation of the cervix. Suspension of the cervix by the sacrouterine 
ligaments, and vaginal fixation of the uterus were performed at this time, but' the 
operation was followed by complete return of the prolapse during the following 
year. Physical examination: Patient’s height 59.2 inches (148 cm.). Hair dis- 
tribution and mammae normal. Horizontal broad shoulders, comparatively small 
hips. The thighs did not touch in the midline and lacked the female softness 
and rounding: husky masculine intersexual type. X-ray of the sacrum shows a 
defect in the arch of the first sacral vertebrae (Pig. 2), although palpation was 
negative. The operation performed at this time consisted of a thorough colpo- 
perineorrhaphy and complete obliteration of the deep, relaxed Douglas pouch 
from above. An enormous dilatation of the transverse colon was found, and 
an incomplete descensus of the ovaries, both located above the innominate line. 
Two years later the patient was admitted for a third time complaining of con- 
stipation which might last as long as four weeks. There was no return of the 
prolapse. The abdomen was slightly distended by a plastic soft tumor occupying 
the entire abdominal cavity, which decreased markedly in size, in one week, after 
twenty-one copious bowel movements of about fifty pounds of feces. As the 
patient felt otherwise well, and was satisfied with the result of the former 
operation for the correction of prolapse, no further therapy was offered. 


Case 2. — ^P. h., Hosp. No. E6273, aged thirty-six years, white, married for sixteen 
years, n o pregnancies, complained of a prolapse of the vagina which appeared 

author from his serv^ice at 

seen In Portion of the 26 nulliparous women has been 

Hospitel. State UnlversUy o? of Obstetrics & Gynecologj;. University 



804 


AJiaRICAX JOURNAL OP OBSTETRICS AND GYNECOLOGY 


fifteen years ago and had become worse during the last year. Physical examina- 
tion: woman of normal female appearance, but unusually stout, with a cystocele 
the size of an orange. X-ray examination of the sacrum showed normal condi- 
tions. Operation: vesicovaginal interposition of the uterus according to Wertheim. 

Case 3.- — C. S., Hosp. Xo. 0085, aged thirty-seven years, white, married 
for fourteen years, had never been pregnant. Onset of menstruation at age of 
fifteen, regular twenty-eight-day cycle with three to eleven days’ duration. Pres- 
ent complaint: attacks of pain in lower abdomen for past several years. Findings: 
large, obese woman, rvho looked markedly older than her age; height 63 inches 
(157.5 cm), weight 149 pounds (64 kilo). Bimanual examination: chronic sal- 
pingitis, fibroids of the uterus, wide “virginal” outlet, the hymen intact but 
jnarkedly stretched. lYhen the patient strained, the anterior and posterior vaginal 
walls bulged through the vulva (Fig. 3) and the cervix could be fell within an 



Pig-. 2. — (Graft). Occult spina bifida (case 1). 


inch of the introitus. The findings aroused the suspicion that the prolapse might 
be associated with some malformation of the sacrum and an x-ray picture showed 
a very distinct defect iu the arch of the first sacral vertebra (Fig. 4). 

Case 4. — S. M., Hosp. Xo. E6774, aged twenty-five years, white, married for 
two years. Xo pregnancies. Onset of menses at eighteen years; irregular. The 
chief complaint was that, for the jjast ten years, the cervix had occasionally pro- 
truded through the introitus. For the same period of time, the patient had suf- 
fered from headaches, easy fatigability, and a feeling of “bearing down.” .Find- 
ings: Obese woman 62% inches (156.2 cm.) tall, weighing 162 pounds (7b"k'ilo), 
with normal hair distribution. Bimanual examination revealed a very wide re- 
laxed outlet with unlacerated hymen which allows the protrusion of the anterior 
and posterior vaginal walls when the patient strains. The uterus is hypoplastic, 
hyperanteflexed, and can easily be pulled down almost to the introitus. X-ray exam- 
ination of the sacrum did not show the expected spina bifida but an unusually wide 
foramen between the last lumbar and first sacral vertebrae (Fig. 5). Colpo- 
perineorrhaphy was performed. 




VON GRAPP: ETIOLOGY OP PROLAPSE 


805 


111 addition to these four nnlliparous women with prolapse — remark- 
able because of the early development of the condition ( Case 1 at seven- 
teen, Case 2 at twenty-one, Case 4 at fifteen years of age), and 
its association with occult spina bifida (Cases 1 and 3), I want to 



Pigr. 3. — Prolapse of both vaginal walls. Nullipara, aged thirty-seven, with occult spina 

bihda (Case 3), 



Fig. 4. — Occult spina biflcla (Case 3, see Pig. 3). 



806 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOQT 


present another patient with oeenlt spina bifida, who had no prolapse, 
but who showed a very similar constitution and appearance. 

Case 5. — I. W., Hosp. No. 62434, aged nineteen years, white, single, nulliparous. 
Menstrual onset at fourteen years; menses irregular. Chief complaint: yellowish 
discharge and pain in the lower abdomen: Findings: Short, stocky^ rather stout 
woman with broad, virile shoulders and. dark complexion. The lower part of the 



Pis. 5. — Nullipara, aged twenty-five, with prolapse of vagina and abnormally wide in- 
tervertebral space. (Case 4.) 

abdomen, the entire perineum and the thighs were heavily covered with dark hair. 
The uterus was sihall, in acute anteflexion, the fallopian tubes swollen and very 
tender. X-ray examination of the sacrum (Fig. 6), showed a distinct occult spina 
bifida. 

This patient should be mentioned since she seems to show, that, al- 
though spina bifida is frequently associated with fiahbiness and weak- 
ness of the pelvic fioor and favors the development of prolapse, it is 
not the only cause. Moreover, the appearance of procidentia in these 



VON GRAFF : ETIOLOGY OP PROLAPSE 


807 


Nvomen is to a certain extent also dependent upon a general functional 
inferiority. It is probably not without significance that this patient 
with hypertrichosis, broad shoulders and heavy build, belongs to the 
masculine, intersexual type. It is to be expected that this girl will 
develop a prolapse soon after her first delivery. 



Fig. 6. — Nullipara, aged nineteen, with occult spina bifida (Case 5). 

II. PROLAPSE IN PAROUS WOMEN 

Table I shows that 438 of the 800 parous women (more than 50 per 
cent) , had normal external genitalia. Since 119 of them had had from 
four to eighteen deliveries, it is evident that a “healthy” woman with 


Table I, Study op 800 Parous Women. 



NUMBER 

OF de- 
liveries 

NUMBER 

OP • 

WOMEN 

NORMAL 

SLIGHT degree OP 
VAGINAL DESCEN- 
SUS, REQUIRING NO 
TREATMENT 

PROLAPSE CAUS- 
ING SYMPTOMS RE- 
QUIRING TREAT- 
MENT 

Group 1 

1- 3 

530 

319 = 60.2% 

138 = 26.0% 

73 == 13.8% 

■ Group 2 

4- 6 

190 

95 = 50.0% 

48 = 25.3% 

47 = 24.7% 

■jjttyysKi 

7-18 

80 

24 = 30.0% 

29 = 36.3% 

27 = 33.7% 

■total 


800 

438 = 54.0% 

215 = 27.6% 

147 = 18.4% 


a sound constitution is able to stand an enormous amount of strain ivith- 
ORt damage to the genital tract. The patients wdth ‘ ' a slight degree of 
■''aginal descensus requiring no treatment,” are grouped in column four, 
although they will be considered “normal.” It should be emphasized 
t lat these women showed such a slight degree of relaxation that they 
cannot be designated as “inferiorly constituted,” since in many in- 












808 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


stances tlie. slight protrusion of the vaginal -wall was due merely to trac- 
tion of sear tissue resulting from old perineal repairs, and did not im- 
press one as a beginning prolapse. Only 28 of these 215 women had 
vague subjective symptoms which may have been caused by the relaxa- 
tion. The diagnosis of descensus, dr prolapse, ivas justified only in 
147, i.e., 18.4 per cent of the 800 women. ■' ' 

The percentage of prolapse shows a marked ilse as the number of 
deliveries increases. This does not in any way contradict the concep- 
tion that the individual constitution is of paramount importance in the 
etiologj^ of prolapse. It is not the purpose of this communication to 
deny entirely the influence of “birth injury,” but rather to emphasize 
the significance of constitutional factors which have been almost over- 
looked. 

It is of interest to note, in support of this conception of the etiology 
of prolapse, that stigmas of asthenic constihdion could he found in more 
than half of all the women listed in column five. 

This applies especially to 22 Avomen, in each of whom the prolapse 
became manifest immediately after the ]nicrperium, although they had 
had, except for a single ease of forceps application, uncomplicated 
spontaneous deliveries. Most of the Avomen AA^ere tAventy to tAA'enty-eight 
years old, with only three “old primiparas,” thirty-one, thirty-six, and 
thirty-six years of age, respectively. Considering the relation betAveen 
the appearance of the prolapse and the age of the AA^omen, there is a 
rapid increase in the incidence of prolapse up to the tAventy-ninth 
year. These Avomen haA’'e a definite, constitutional, functional in- 
feriority, and there are certainly some among them aa'Iio Avould have 
developed prolapse even Avithout the damage incident to parturition. 

The greatest number of prolapses appeared, as A\’as expected, betAveeii 
the forty-fifth and fifty-fifth years. In these AA’omen, the pelvic tissues 
had sufficient elasticity and tonus to prevent the early development of 
prolapse after childbirth, and the moderate degree of constitutional in- 
feriority became manifest only during the years of physiologic decrease 
of functional efficiency. 

After this period, there is a rapid decline in the frequency of pro- 
lapse, because the AA'omen aa4io passed through the climacterium AAUthout 
damage are those AA'hom AA-e may call “normal,” and aa4io AA'Ould there- 
fore not be likely to develop prolapse. In the great majority of eases 
of postmenopausal procidentia, it Avill be found that the derangement 
Avas present or had started many years before, at the beginning of or 
during the change of life. 

The iiiA'estigations presented in this ]iaper, aside from their scientific 
interest, are not Avithout practical A'alue. The entire make-up, the 
constitution, of the patient may occasionallj’^ haA'e more Amlue in regard 
to etiology and prognosis than a careful physical examination and 
laboratory te.sts. Consideration of constitutional variations may, espe- 



VON GRAFF : ETIOLOGY OF PROLAPSE 


809 


cially in the pre- and postnatal patients, enable one to recognize in 
advance those women who are more endangered by pregnancy and 
parturition, and who therefore require more than the ordinary care. 

CONdLUSIONS 

1. The etiology of prolapse is largely a constitutional problem. 

2. Birth injury acts merely as an initiating factor in the production 
of prolapse. 

3. In healthy, ideally constituted women, more than 50 iier cent never 
suffer from prolapse, regardless of the number of children they have 
borne. 

4. Prolapse develops most commonly durmg the climacterium, at 
which time the tissues of the body become relaxed and less resistant, so 
that a slight degree of constitutional inferiority may become manifest. 

5. The early appearance of prolapse shortly after the first delivery 
stigmatizes the patient as being constitutionally inferior. 

6. Retrodisplacement of the uterus by itself does not favor the de- 
velopment of prolapse, but it may be of significance as a symptom of 
the patient’s constitutional inferiority. Therefore, it is not justifiable 
to operate upon patients with movable retroflexions under the pretense 
of prophylaxis. 

REFERENCES 

Gi'aff, E.: Ztsehr. f. Konstitutionslelire 11: 170, 1925. Mathes, P.: Arch. f. 
Gynak. 77: 357, 1906. Mathes, P. ; Die Asthenie, der Infantilismus, Berlin, 1912, 
S. Karger. Matlies, F.: Zentralbl. f. Gynak. 45: 1429, 1921. Mathes, P. : Ztsehr. 
f. angew. Anatomie u. Konst. 6; 333, 1920. Mathes, P.: Halbaii- Seitz, Biologie und 
Pathologie des Weibes 3: 1-140, Berlin, Wien, 1924, Urban u. Schwarzenberg. 
Martin, A.; Der Haftapparat der weiblichen Genitalien. Eine anatomische Studie. 
I. Theil: Beckenbindegewebe, Pascien nnd Muskelapparat, Berlin, 1911, Karger. 
Tandler, J., and Ealban, J. : Anatomie und Aetiologie der Genitalprolaps beim 
Weibe, Wien u. Leipzig, 1907, W. Brauniuller. Stiller, B.; Die asthenische Kon- 
stitntions-krankheit, Stuttgart, 1907, Enke. TFatMns, T. J.; Surg. Gynee. Obst. 2: 
(559, 1906. Watkins, T. J.: Am. J. Obst. 65: 225, 1912. 



AVITAmNOSIS AS A LIKELY ETIOLOGIC PACTOB IN POLY- 
NBUEONITIS COMPLICATING PREGNANCY, WITH THE 
REPORT OP A CASB'^ 

Ralph Luikart, M.D., P.A.C.S., Ohaha, Neb. 

(From the Department of Obstetrics, Creighton Vniversity) 

' I ""HE object of this communication is twofold : first, a plea for clini- 
A cal and pathologic studies of the nervous sj’^steni in hyperemesis com- 
plicating pregnancy; second, to report observations made on the 
nervous manifestations in a fatal case of vomiting of pregnancy, and, 
based on a similarity of these manifestations and pathologic sections 
(polyneuritis) to beriberi, Korsakow's syndrome, pellagra, etc. (Pigs. 
1 to 6), to suggest vitamin B eomplext lack as an etiologic factor in 
this disease complex. These obsei*vations we hope may prove to be of 
some value in the constant effort which is being made to clear up this 
ever perplexing problem. 

Berkwitz and Lufkin report is a A'ery complete summary of some- 
what similar eases collected from the literature, numbering over 500 
and dating back to 1854. Of this group only 56 cases were typical, 
4 of which were personal cases reported in detail. Regardless of the 
fact that the uterus was emptied in all 4 cases, three artificially and 
one spontaneously, the disease progressed to a fatal termination in 
3 out of the 4 cases (75 per cent mortality). In their conclusions they 
suggest abortion as soon as neurologic symptoms appear. Plass- re- 
ported 8 personal cases in detail Avith an 85 per cent mortality. Seven 
of the 8 patients died. The uterus was emptied in 5 cases, in 4 of 
which the disease progressed to a fatal termination. The fifth was 
improving at the time of the report. 

A study of these cases sIioavs that, if the ner^mus element of the 
disease is advanced, abortion is of no aAmil, definitely indicating that 
some concomitant etiologic factor exists in addition to the pregnancy, 
or that some complication develops as a sequela of the disease or from 
some shortcoming in the treatment during the pernicious Ammiting of 
pregnancy. 

REPORT OP case 

E. G., married, aged thirty-one years, tall, Avell proportioned, Aveight 210 pounds, 
para iii. First pregnancy complicated by A’omiting; spontaneous abortion at two 
months. Second pregnancy spontaneous deliveiy at seven and one-half months, 
living child now eight years old. Previous history and family history negative. 

*Read at the Fourth Annual Meeting of the Central Association of Obstetricians 
and Gynecologists, Memphis, Tenn., September 15-17, 1932. 

fAUtamin B. complex refers to the complex containing Vitamin Bi the antineurltic 
vitamin, and Vitamin B:, the antipellagra vitamin. 

810 



LUIKART ; AVITAMINOSIS 


811 


I first saw the patient in February, 1931, with no complaint except inability 
to conceive. The physical examination, including complete blood count, Wasser- 
maun and urine, was negative except for a 3+ erosion of the cervix with a pro- 
fuse discharge. Air insufidation. was positive. Hysterosalpingogram refused. Cau- 
terization was advised but because of nervousness she postponed it until Septem- 
ber, 1931. She menstruated once after the cauterization. Eesult of cauterization 
excellent. January 13, 1932, she reported that she had not menstruated since 
November 16 and rvas vomiting a great deal and had several small ulcers in her 
mouth. She had lost 20 pounds. The blood pressure was 130/75, temperature 
98.6°, pulse 90. The urine was negative. 

The ulcers were touched with silver nitrate, 10 per cent. General prenatal 
advice was given with suggestions in regard to the nausea, and elixir luminal — 
drams 1 q. i. d., fifteen minutes a. c. was ordered. 

The nausea persisted, gradually growing more severe. There were complete 
remissions of twenty-four to forty-eight hours during which time large quantities 
of water were taken. Each time it seemed she had turned the corner and the 
period during which nausea might be expected was past. There would be some 
temporary improvement followed immediately by a severe increase of nausea, and 
marked restlessness and irritability. After one of these remissions during which 
there was an intake of some food and 3600 e.c. of liquids a day for two days 
she became hysterical and complained of extreme weakness. She retched until she 
brought up blood. Her condition became so severe it was necessary to hospitalize 
her (March 16), She was well past her third month of pregnancy. She had 
lost 50 pounds in weight. 

Treatment consisted of isolation, nothing by mouth, hypodemioclysis and intra- 
venous saline and glucose to protect and build up the glycogen reserve of the liver 
as originally suggested by Titus.® In addition she was given luminal sodium 
hypodermically, grains 1% q. i. d. as originally suggested by me.^ 

During the first five days of hospitalization her intake of saline and 10 per 
cent glucose by mouth, rectum and parenteral administration totaled 20,000 e.c. 
{vitamin free nutrition). The relief was only temporary and her pulse gradually 
rose to 100. 

A duodenal tube was passed and over a period of three days more than 3,000 
e.c. of orange juice, broth, lactic acid milk and cream and glucose wmre retained 
(note the vitaimin-coniaining food and the result). The tube was removed and the 
patient retained goodly amounts of food given by mouth. A decided anorexia 
persisted. The vomiting of pregnancy wms relieved as a result of treatment, but 
the vitamin deficiency in this therapy as commonly e^nployed must he acknowledged. 

March 31 the patient had passed the seventeenth week of pregnancy. She left 
the hospital eating fairly well, with no emesis, weak but able to walk about. The 
nervousness had almost subsided. 

Laboratory; Daily urine examinations were negative after the fourth day in 
the hospital. R.B.C. 4,170,000, lib. 90 per cent, W.B.C. 10,800, poljmiorplionuclears 
<0, lymphocytes 30. B.M.E, -h 20 (a normal rise during pregnancj'). The metabolic 
test was done because of the persistent tachycardia, extreme irritability and dry, 
scaly skin. The Wassermann was negative. 

The neurologic examination was practically negative except for wetikness and 
hjqiersonsitivity. All reflexes were hyperactive. Tliere was some tenderness in the 
log muscles, especially of the calves. Ko pain. Leg extension and leg raising was 
good. There was a constantly increasing flaccidity of the muscles. The calves 
Imiig down like bags of water. Her speech was whiney and thick. 

Three days after going home the anorexia returned. There was little or no 
nausea but the weakness increased and nine days after leaving the hospital she 



812 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 



Fijr. 1. — Antei'ior hoin cell. Case of Dellasra.* 



Fis:. 2. — Marchi degeneration in lumbosacral 
nerve. Case of pellagra. 




Fig. I. — Marchi degeneration in lumbosacral nerve. 
(Borkwitz and Lufkin case.) 


Fig. 6. — Marchi degeneration in lumbosac- 
ral neri’e. Author’s case. 





LUIKART ; AVITAMINOSIS 


813 


IjeL-anie mentally confused, her vision became blurred, her speech less clear, tachy- 
cardia more pronounced and numbness of the feet developed, the latter thought to 
be due to the luminal sodium. Nystagmus, both perpendicular and transverse, 
developed. She held her eyelids half closed, giving a squint-like appearance, like 
a devitaminized animal. She could not tell the time of day or day of week. Her 
tongue was thick, red and dry and of a granular appearance. The reflexes of the 
upper extremities were normal, hand clasp of fair strength. The knee jerks were 
absent. She cried out when her legs were touched or an attempt was made to 
raise them to test for knee jerks. Tliere was no clonus, no Babinsky, and no 
Oppenheim reflexes. Control of the rectal and bladder sphincters was lost. The 
symptoms increased until there developed a condition typical of Korsakow’s 
syndrome. 

A diagnosis of polyneuritis was made and confirmed bj' Dr. George Neuhaus 
who advised administration of vitamin B (antineuritic).^ Brewer’s yeast was 
given in doses of drams 2 q. i. d. (Rice polishings* as prepared by Seidelt’s 
methods could not be procured.) At the end of thirty-six hours the tenderne.®s 
was almost gone from her legs, but she could not raise her legs from the bed. 
The hyperesthesia had subsided. Her eyes appeared quite normal. She said she 
felt better, but the heart rate had reached 130. It was impossible to get her to 
swallow sufiicient liquids. Her tongue was so swollen that it filled her mouth. 
She was dehydrated and it was deemed necessarj' to get her back into the hos- 
pital. She became unable to retain the j'east. 

She entered the University Hospital April 16. Examination of the eye grounds 
by Dr. Stokes showed in the right eye: definite blurring of disc margin but no 
elevations. No hemorrhage or exudate. Vessels normal. Left eye; narrow flame 
hemorrhage between superior temporal artery and vein; 1 disc diameter long and 
twice the width of the vein, 1 disc diameter out from the nerve. No definite 
blurring of disc or other changes. 

April 17. Blood count: Hb. 72 per cent, R.B.C. 3,960,000, W.B.C. 8,600, poly- 
morphonuclears 83, lymphocytes 12, moiumuclears .1. Urine negative. Blood Was- 
serraann negative. 

Blood chemistry ; Nonprotein nitrogen 30.1 mg. ])er cent. Chloride 497 mg. 
per cent. 

Linnhar juncture ; pressure 6 mm. Hg. spinal fluid Wassermanii negative. Pro- 
tein 10 mg. per cent. Cell count 2, uric acid 3.7 mg. per cent, serum nonprotein 
nitrogen 23.4 mg. per cent, total serum protein 5.9 per cent, total serum albumin 
•1.7 per cent, cholesterol 176 mg. per cent. 

Blood pressure; Systolic 135, diastolic 70. Temperature 99°, 100° at 2, and at 
4 A.xi. 103°. Pulse 160. Lower extremities flaccid. 

The patient’s condition rapidly grew worse in spite of administration of quan- 
tities of glucose and saline by vein and under the skin. She died April 18. 

Autopsy; All gross findings were negative. Sections of the liver, kidnej^ and 
spleen showed cloudy swelling. Gross examination of nerves was negative. Alicro- 
■'^copieall y the sections revealed definite degeneration of the anterior horn cell with 

^'.ve polishings prepared by Block and Cowgill has been injected sub- 
uianeousiy and intravenously wdth success. alOiough injection is painful because of 
Wn substance; personal communication Dr. Cowgill to Dr. Victor Levine. 

1932. (Rice polishings extract is available.) 


of Marchl degeneration (right column) and neurone changes in an- 
nai cv column) In pellagra (Figs. 1 and 2) in neuronitis of preg- 

(FicJ Berkwitz and Lundn,” Figs. 3 and 4); and in the author' .s case 

llli stV-ntp#^., ■ r three cases show definite Marchi degeneration in the sections 
show ta'^cn from the lumbosacral nerves. Tlie neurones in each case 

Is an nuclei and loss of Nissl substance. In the autlior’s case there 

of the PoBmorphonuclear and plasma- cell, and definitely more degeneration 

01 the neurones a.s shown by their more rounded contour. 



814 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


occasional polymorphonuclear leucoe3'tes and plasma cells. The lumhosacral nerves 
showed definite Marchi degeneration. 

It was definitelj’' observed tlironghout the illness of the patient that 
when her system was flooded with large quantities of Avater and glu- 
cose, Avhich of course are Autamin free, she shoAA'ed a temporary im- 
proAmment folloAved immediately by an exaggeration of symptoms 
unless Adtamin containing nutrition Avas administered Avith the Avater 
and glucose. This ohserAmtion is in close keeping AAdth CoAvgiH’s' 
Avork in AAdiich he has pointed out that the expression “toxemia” is 
draAvn into service at present as an explanation for a variety of mani- 
festations of disease for AAdiich no clearer intei’iiretation is available. 
Startling cures that occur folloAidiig the administration of Adtamins to 
so-called polyneuritic pigeons, in AAdiich nerve degeneration can he 
demonstrated so readily, can hardl}'- be explained as due to sudden 
correction of the degeneratWe changes in nerves. This has led many 
of the inA’’estigators to faAmr the idea of toxemia from toxins injected 
Avith food or from faulty metabolism. One of the methods supposed 
to relieve such a condition consists in “Avashing out” the system by 
liberal intake of Avater and producing a vigorous diuresis. This pi’oc- 
ess is sometimes accelerated by the parenteral administration of fluids. 
The plan has been put to the test in the laboratories at Yale in the 
Physiological Chemistry Department by CoAvgill and his collaborators 
in the ease of animals deprived of their optimal intake of vitamin B 
complex hy a selected regime. When they Avere given large amounts 
of Avater it Avas found, contraiy to AAdiat might be anticipated, that the 
time required for the appearance of the anorexia charactei’istic of this 
dietarjr essential Avas markedly shortened. Instead of being protected, 
the animal Avas rendered more susceptible to the deficiency of the 
vitamins. CoAvgill points out that this result is not in harmony Avith 
the hypothesis that the symptoms of deficiency of Aritamin B complex 
are essentially those of toxemia. The urge to eat Avas restored hj^ 
undifferentiated- Autamin B complex. His explanation of the results 
of the forced fluids is a temporary relief of the anorexia and anly- 
dremia, but the removal of the Autamins by the diuresis may actually 
be detrimental in that it Avashes the Adtamin B complex from an al- 
ready partially depleted body. Certainly sufficient CAddence is at 
hand, he concludes, that trials of the administration of some potent 
source of vitamin B complex are Avarranted. In any event the Amgiie 
assumption of an existing toxemia may no longer he entirelj’’ sufficient 
to the clinician. 

CoAvgillS" ® also points out the Avell-knoAAui fact that the capacity for 
storage of Adtamin B complex in the body is rather limited. Increased 
exercise definitely decreased the period required for the development 



LUIKART : AVITAMINOSIS 


815 


of anorexia characteristic of lack of vitamin B complex. These ob- 
servations are considered to be supported by the fact that vigorous 
exercise increases voluntary food intake. Furthermore, the vitamin B 
complex intake requirement of an animal is significantly increased 
when the metabolic rate is increased by thyroid administration. 

There is a normal increase of 20 per cent or more of the metabolic 
rate during pregnancy.^®’ This fact, in view of Cowgill’s observa- 
tions, would make logical the assumption that the vitamin B complex 
is endangered even during normal pregnancy. 


SUMMARY 


1. Modern scientific therapy of cases of pernieious vomiting results 
in avitaminosis. 

2. The usual 20 per cent or more elevation of the basal metabolic 
rate during pregnancy may disturb the vitamin B complex balance. 

3. The majority of the advanced cases of polyneuronitis with preg- 
nancy reported have shown no cessation of the disease by abortion. 

4. There is close relationship between the clinical sjonptoms and 
pathologic findings to Korsakow’s syndrome. Here the neuritis is 
supposed to be due to the constant vomiting of alcoholism, and ulti- 
mately to avitaminosis. 

5. Pathologic sections of the neurones in beriberi, pellagra, and 
scurvy are similar to the sections in the cases of polyneuronitis of 
vomiting of pregnancy reported by Berkwitz and Lufkin, and in the 
author's case. 

6. The case reported responded to “Avashing out" with vitaminless 
glucose and saline as obseiwed by CoAvgill. There ivas a definite re- 
mission of many of her symptoms after forced feeding of vitamin B 
complex for tivelve hours. 

7. Neurologic examinations in hyperemesis gravidarum should be 
frequent and an attempt should be made to keep up the vitamin bal- 
ance. 


ackno-wledge the kindness of Dr. Victor E. Levine. Creighton Medical Col- 
iCoG, In securing the cuts of the pellagra case. 


REFERENCES 

(1) Berlcwits, 21. J., and Lufkin, N. E.z Surg. Gynec. Obst. 54: 743, 1932. (2) 
ites, E. D.; Read before joint meeting Omalia-Douglas County and Missouri 
\aUey Med. Soc. March 29, 1932. (3) Titus, Paul: J. A. M. A. 85: 4SS, 1925. 

(4) Lmkart, Balpli: An. J. Oust. & Gyneo. 5: 410, 1923. (5) Eoohler, JB 

Aflj/mo?.d; J. A. M. A. 96: 675, 1931. (6) Brit. M. J. p. 862, 1931. (7) CoivgiU, 

o. Ji., Eoscnhcrg, U. A., and Bogoff, J.: Am. J. Physiol. 95: 537, 1930. J. A. M. 

96; 094, 1931. (8) Cowgill, G. B., Bosenlerg, E. A., and Bogoff, J.: Am. J 

Physiol 98: 589, 1931. J. A. M. A. 98: 741, 1932. (9) Eimwiclt, E. E., Godfarl, 
CowgiU, G. B.i Am. J. Physiol. 99: 689, 1931. (10) Baer, J. L.; Am. J. 
fr Sandiford and Wheeler: J. Biol. Chem. 62: 329, 1924. 

J'’'"'®- 156, 1913. (13) Berkwitz, N. J., and 

■Ui'Ain, A. 27.: Surg. Gynec. Obst. 54: 743, 1932. 

1530 Medical Arts Building, 



^ CONSIDERATION OP SCHNEIDER MODIFICATION OF 

T^E ASCHHEIM-ZONDEK TES T A.S RELATED 

-TO privateTractice'' 

Harold S. Morgan, M.D., Lincoln, Neb. 

(From the Department of Ohstetrics and the Fxperima}tal Lahoratorp of the 

Lincoln General Hospital) 

T T IS not SO much the purpose of this paper to report a series of cases, 
* bnt rather to detail certain considerations of the Aschheim-Zondek 
test, that make for its practical application in private practice. 

The Board of Trustees of the Lincoln General Hospital have re- 
cently caused to be built, and the Staff has equipped, an animal expe- 
rimental laboratory, which serves as a workshop for anj'" Staff mem- 
ber with a problem that requires the use of test animals. This 
laboratory seiwes the members of the Obstetrical Department as a 
place to conduct the pregnancy tests, as well as providing adequate 
quarters in which to care for the animals used. 

Bearing in mind tliat this work was to he done, not hy technicians or medical 
students, hut hj’ the obstetricians themselves as a part of their private practice, a 
method had to be developed that would entail: first, an adequate supply of test ani- 
mals, second, a minimum loss of time and third, sufficiently simple to avoid the 
necessity of help in injecting and examining the rabbits. 

In choosing between the various modifications of the Aschheim-Zondek test our 
preliminary experiences in procuring adult rabbits and isolating them for given 
periods of time was unsatisfactory. Babbits that had been certified to us as hav- 
ing been isolated for three weeks were found on section to be pregnant. The 
repeated injections and the length of time necessary after injection before the 
test could be read, together with the oftentimes confusing picture of an adult 
rabbit ovary were disadvantages that led us to adopt the Schneider technic; As 
Dr. Schneider pointed out in Iris paper before this society last year, the finding 
of one hemorrhagic follicle in each ovary is sufficient to make a positive diag- 
nosis. ITailure in demonstrating the hemorrhagic follicles leads at once to a nega- 
tive diagnosis. We feel that the clear-cut reaction obtained wlten juvenile rab- 
bits are used is a decided advantage of this modification. 

The next problem we faced was that of securing a supply of rabbits. We 
were able by offering slightly more than the market price of meat rabbits, to 
obtain a rabbit breeder who would segregate the males from the females in each 
litter after weaning and at the fourteenth week, house the females in separate 
cages. If at the end of eighteen weeks the does have not been used, they are 
used by the breeder for any purpose. The market price for meat rabbits in this 
community is seventy-five cents and for twenty-five cents more, we are assured of 
a constant supply of dated, virgin does. In order to facilitate the ordering and 
paying for the rabbits, my office has been made the clearing house and whenever 

•Read at the Fourth Annual Meeting of the Central Association of Obstetricians 
and Gynecologists, Memphis, Tenn., September 15-17, 1932. 

816 



MORGAN ; SCHNEIDER MODIFICATION OF ASCIIMEIM-ZONDEK TEST 817 

a rabbit is needed, my secretary is notified and orders the rabbit, usually in the 
afternoon in order that the breeder need not make several trips to the hospital. 
At the end of the month each member of the department having ordered rabbits 
receives a statement from the secretary and the breeder is paid in a lump sum. 
This system has now been in operation seven months and has proved at once prac- 
tical and economical both in time and money. 

As mentioned before, the tests are conducted by the individuals of the depart- 
ment and usually in the late afternoon or evening at a time when assistance is 
difficult to obtain. After our entirely unsatisfactory experiences in injecting the 
rabbits without help. Dr. H. E. Harvey devised the box illustrated in Pigs. 1 and 



Fis. 3. 


2- A single trial of the box served to convince us of its absolute value and now 
wo would hesitate to inject a rabbit without its aid. Pig. 2 demonstrates the 
box in operation. The top piece being movable, any size rabbit may be held 
firmly and cannot jump at the wrong moment. It is our practice to place the 
animal in the box and after rubbing the ear briskly with a pledget soaked with 
^■ylol, an electric light is placed in front of and below the box. The xylol acts 
as a local dilator, rapidly causing a dilatation of the ordinarily small marginal 
ear vein to four or five times its normal size. The light transilluminates the 
•^ar, causing the dilated vessels to stand out sharply and one can determine at 
once that the needle remains in the vein. This feature, though not necessary in 
well-lighted quarters is quite worth while in artificial light. 



818 


AMERICAN JOURNAL, OP OBSTETRICS AND GYNECOLOGY 


Frequentlj^ it becomes advisable to section the test animal, rather than sacri- 
fice it, particularly since it has been shown that even following a positive reac- 
tion, the rabbit may be used again three to four weeks later for pregnancy tests 
or for other purposes. To do this a suitable anesthetic must be used, and to fit 
our particular requirement, the anesthetic must of necessity be sufficiently sim- 
ple to permit of administration by the operator. To this end, inlialation anes- 
thetizes were discarded and sodium amytal was adopted. Here our experience, 
unlike that of others has been entirely satisfactoiy. It is our practice to dis- 
solve the contents of one capsule of sodium amytal (3 gr.) in 0 c.c. of sterile 
water. Solution is accomplished by bringing the mixture just to a boil in the 
test tube. The amytal goes into an opalescent suspension at the boiling point. 
When cooled down to body heat it is injected slowl}' intravenously. We find that 
the average fifteen- to eighteen-week rabbit will require 2% gr. of sodium amytal. 
Care is exercised to see that the injection is carried out slowly, inasmuch as the 
only mortalities that we have had, have occurred after rapid injection. The 
syringe and needle used to inject the amytal need not be sterile. As soon as the 
injection is completed the rabbit is placed in the operating trough (Fig. 3; and 
strapped in position. This trough is simplj- a modification of the operating boards 
in use in dog surgery- courses iu our medical schools. The bellj- is then prepared, 
first clipping the fur from the midline and appl}’ing a depilatory compound, made 
up of barium, gray, 2 ounces; zinc oxide, 2 ounces; and starch, 3 ounces. A por- 
tion of this is mixed into a thick paste ■with water and applied to the desired 
area. When dry it is rubbed off, bringing the fur with it. By the time the belly 
is prepared and painted with mercuroehrome the animal is sufficiently anesthetized 
for surgery. 

In my early experience with the pregnancy test, strict aseptic technic was car- 
ried out in closing the laparotomy. Sterile drapes, gowns, gloves, and instru- 
ments were used. However, the costliness of this procedure, both in sterile sup- 
plies and time consumed, led me to deliberately violate all custom and discard 
all sterile supplies, save the few easily boiled instruments. Sutures have been 
purposely dragged over the fur of the animal and to date no infections have 
developed. Our technic now consists of elevating the i-abbit in Trendelenburg 
position, opening the abdomen in the midline, pushing back the intestines -with a 
piece of sterile gauze, and inspecting the ovaries gently. The belly muscles and 
peritoneum are approximated with a continuous black silk suture, the same suture 
being used to close the skin, thus making a two-layer closing. The animal is then 
placed in a warm clean cage and allowed to recover. 

In presenting tlie series of tests conducted, no attempt is made at 
this time to detail the iudividnal cases, the detailed analysis being 
reserved for a later communication. The report covers the tests per- 
formed by Drs. Hansen, Harvey, Mnngei’, "Whitham and myself and I 
desire to express my appreciation to them for their kindness in per- 
mitting me to use their records. 

Out of our series of nearly 100 cases in which the. test has been per- 
formed, we have 87 in which the results have been proved clinically. 
No test has been utilized for this report in which the actual condition 
has not been verified either by operation or the subsequent history of 
the patient. Of the 87 tests, 2 were proved wrong, both of the errors 
occurring in the group reported as negative. None of the group re- 
ported as positive were found to be wrong. The percentage of error, 



STEIN AND COPE; TRICHOMONAS VAGINALIS (dONN:^) 


819 


then in onr gronp of 87 cases will be 2.2 per cent, thus corresponding 
favorably with country-wide estimates of the reliability of the test. 

In conclusion, it is of interest to note the demand on the part of 
both patients and doctors for this test, since its introduction. Those 
of us doing the test have almost a constant demand from surgeons and 
internists to help them rule out tumors, ectopic gestations, and 
hydatid moles, and with the facilities at our disposal we are able to 
meet these requests promptly. 

In our hands the Schneider technic is entirely satisfactory and the 
plan outlined in this communication is peculiarly fitted to the require- 
ments of private practice, where the facilities of the teaching hospital 
with its laboratories and extra help are not available. 

723 Sharp Building. 


TRICHOMONAS VAGINALIS (DONN^l)^' 

Irving F. Stein, B.S., M.D., and Elizabeth J. Cope, B.S., Chicago, III. 


^ BEAT interest has become manifest in the subject of Trichomonas 
vaginalis vaginitis in the past few years as evidenced by the numer- 
ous publications on this subject in almost every language in the current 
medical literature. In revieiv, there is almost complete unanimity of 
opinion as regards the clinical picture of this disorder and in conse- 
quence its ready recognition has become common. The source of the 
trichomonad and its pathogenicity, however, has become the subject 
for investigation, there being still a wide divergence of opinion. 

The present report encompasses a study of 61 additional cases since 
our previous publications.^’ - In this we aimed to discover the source 
of vaginal infection with triehomonads through an investigation of the 
various sites of trichomonad incidence in the body. In order to secure 
sufficient material for this work, the routine urine specimens from the 
prenatal patients in the Mandel Clinic of the Michael Reese Hospital 
were examined for the presence of triehomonads. During nine months 
we examined a total of 2462 voided urine specimens from 889 patients. 
Triehomonads were found in the urine of 88 patients, an incidence of 
10 per cent. Forty-one patients from this clinic group, 3 private 
prenatal patients, and IT gjniecologic patients (7 private and 10 clinic) 
were examined for the presence of triehomonads in the four commonly 
recognized sites of infestation ; the vagina, the gums, the intestinal tract, 
and the bladder. Warm stools after saline catharsis (magnesium citrate) 
were ex amined by the hanging drop method, and cultures were made to 


iSibe°r Association of Obstetricians and 

^rnecoloEiical Department of the Michael Reese Hospital 
Albert Kup^ienhehncrF.ml! ''^ Research, supported by a ^ant 



820 


AI^lERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


ascei’tain the presence of trichomonads and yeasts. Catheterized speci- 
mens of urine were obtained and were immediately centrifugalized; the 
presence of trichomonads and yeasts in the sediments was determined 
by hanging drop examination and by cultures. The gums of each patient 
were rather vigorously rubbed A\dth a sterile cotton applicator which 
was then placed in 3 c.c. of placenta broth for transportation to the 
laboratory. From this suspension hanging drop examinations and cul- 
tures were made. Vaginal secretion was obtained and examined bj’’ the 
method described in our previous papers. (Gram stains were made for 
detection of gonococci and other bacteria.) 

Fresh hanging drops were used in examining material from the four 
sites for living trichomonads. Three subplants were made; one on 
Sabouraud’s medium for the cultivation of yeasts, a second in Locke’s 
solution w'ith 5 per cent human blood serum covering placenta agar 
slants and a third in the same solution covering blood agar slants for 
the growth of the trichomonads. 

In this group of 61 patients trichomonads were seen on direct exam- 
inatioir and were grovm in artificial culture mediums from the vaginal 
secretions in 58 patients, from the catheterized urine in 5, from warm 
stools in 3, and from the gums in 4 patients. One patient revealed 
trichomonads in the vagina, bladder, and gums. The 3 patients not 
yielding the vaginal parasite were from the clinic prenatal group. One 
of these had trichomonads in one of the three voided urines examined 
before delivery, but diiuct smears and cultures from the catheterized 
specimen of urine, vaginal secretion, and stools were negative after de- 
livery. Curiously enough, however, at the same time cultures from 
the gums were positive for trichomonads. One prenatal patient showed 
living trichomonads in one of thi*ee voided urine specimens examined 
before delivery, but none could be found in any of the four sites 
examined ten days and six weeks after deliveiy. The same experience 
was encountered in a second case with the exception that the living 
trichomonads were found in all of five voided specimens examined be- 
fore delivery. The possibility of these individuals acting as temporary 
carriers of the protozoa must be considered because none of them com- 
plained of any of the symptoms commonly associated with vaginal in- 
fection with Trichomonas vaginalis even when questioned carefully. 

Fx'om these results it is obvious tliat whereas there are cases where 
trichomonads are found in more than one location in the same in- 
dividual, it is not usual. They are probably independent rather than 
cross infections, vdth the possible exception of the dual incidence in the 
vagina and bladder. 

Among the 58 patients we found yea.sts in addition to the trichomonads 
in the vaginal secretion of 10; 7 of these were prenatal and 3 were 
gynecologic. Yeasts were obtained on culture from the gums of 15 
patients, one of whom also had Trichomonas bucealis. Fi’om the stools, 



STEIN AND COPE : TRICHOMONAS VAGINALIS 


821 


yeasts were found in 27, one of which also contained Trichomonas 
hominis; in the 5 cases where yeasts were found in the catheterized 
urine specimens, no triehomonads were found. These figures indicate 
a coincidental incidence rather than a habitual association of tricho- 
monads and yeasts. 

An effort was made to examine a number of husbands for a possible 
conjugal source of infection, but only 3 men appeared for investigation. 
In 2 of the husbands no flagellates w'erc found when voided urine speci- 
mens and prostatic secretions were examined by fresh hanging drop and 
culture methods, although one of the men had been under a urologist’s 
care for a nonspecific urethritis. The third, a colored man, yielded 
triehomonads in the prostatic secretion and in the voided urine, and his 
wife was found to have a typical Trichomonas vaginalis vaginitis. We 
were unable to determine which partner was first affected. This is the 
only conjugal example w'e have observed. 

Nothing has been proved concerning the infectiousness of Trichomonas 
vaginalis vaginitis. It is interesting to note in this connection that 
among 4 little girls until Trichomonas vaginitis, observed by Frankenthal 
and Kobak^ in our vaginitis clinic, two were sisters. The mother of 
the children was examined and found to have a similar infection, and 
investigation of the home revealed very poor hygienic conditions. Three 
of the 4 cliildren in this report had not jmt menstruated, and the fourth 
had one period six months previously. 

The possibility of foods and their handling as a factor in the trans- 
mission of the parasite, and incidentally the question of the effect of 
vitamines on the growth of the parasite, prompted us to make a series 
of cultures using bean sprouts and lettuce as mediums. Canned bean 
sprouts in their own liquid were used for one group, and a suspension 
of shredded lettuce in physiologic salt solution was used for the other. 
These and other mediums used routinely as control cultures received 
simultaneous inoculations from actively growing cultures of Trichomonas 
vaginalis. No growth or survival of the triehomonads was found in 
any of the tubes containing the lettuce suspension when examined at the 
end of twenty-four and forty-eight hours’ incubation at 37° C. At the 
end of twenty-four hours’ incubation a few motile triehomonads were 
present in all tubes containing bean sprouts, but none were found at 
the end of forty-eight hours’ incubation, indicating a survival rather 
than active growth of the protozoa. This result suggests the possibility 
of transmission of Trichomonas vaginalis by means of material carriers 
when moisture and temperature conditions are favorable. 

FURTHER OBSERVATIONS OP CULTURAL CHARACTERISTICS 

In isolating the triehomonads from various sources, certain cultural 
variations were noted. Continued studies in the morphology of Trichom- 
onas vaginalis were made, using fixed smears stained Avith iron- 



822 


AMERICAN JOURNAE OP OBSTETRICS ANO GYNECOLOGY 


hematoxylin, hanging drops of living flagellates stained with vital stain, 
and the dark field microscope, klotion pictures of the microscopic dark 
field were also obtained. 

Two of the most commonly observed characteristics of the discharge 
of Trichomonas vaginalis vaginitis are the foul odor and the bubbly 
consistency of the discharge. A similar odor is found in artificial cul- 
tures of Trichomonas vaginalis accompanied by the presence of large 
amounts of gas. This gas production frequently forces the slants to- 
ward the toil of the test tubes, even when very large tubes are used. 
Frequently a bubbly froth is present on the top of the cultures. The 
parasite grows well when either blood agar or placenta agar slants are 
used as a base, but apparently more luxuriantly with the latter. The 
trichomonads which we isolated from the stools in our cases grew veiy 
poorly when placenta agar slants were used, but with blood agar slants 
were readily cultivated with the formation of a small amount of gas. 
These cultures produced a characteristic odor which differed noticeably 
from that of the cultures of the vaginal jiarasite. The Trichomonas 
buccalis grew readily mth the formation of a moderate amount of gas 
when placenta agar slants were used, but scantily, if at all, when the 
blood agar slants were tried. The odor of these cultures differed from 
the two mentioned above and resembled very closely that of foul breath. 
The trichomonads isolated from the bladder were apparently in aU 
respects similar to those isolated from the vagina. Before attempting, 
however, to draw any conclusions as to the significance of the cultural 
characteristics described it is, of course, necessary to take into considera- 
tion the fact that these were not pure cultures of trichomonads. The 
associated bacteria in the material from which the cultures were made 
(i.e., the vaginal secretion) also grew in these cultures, and their pres- 
ence must be evaluated as contributing factors to these cultural char- 
acteristics. 

It is quite obvious, however, from our observations, that the tricho- 
monads found in the voided urine in women are almost invariably de- 
rived from the vagina. Possiblj’" some of those found in stools (Hees^ 
found them in 47 patients) may also be contaminations from the vagina, 
as the vaginal discharge in Trichomonas vaginalis vaginitis is often 
very profuse and liquid. Straining at stool can be conceived to force 
droplets of vaginal discharge into the specimen. On the other hand, the 
infection of the vagina by trichomonads has not been proved to be the 
result of transplantation of the parasite from other foci of incidence in 
the individual. When the taxinomic differences reported by Bland 
et al.'^’ ® and the cultural differences reported by us are considered, in 
addition to the rarity of multiple incidence of trichomonads in various 
typical locations in the body, it appears neeessaiy to consider the 
trichomonad associated mth Trichomonas vaginalis vaginitis as a specific 



STEIN AND COPE : TRICHOMONAS VAGINALIS 


823 


protozoan localizing in the genitourinary tract, the source of which 
must he sought elsewhere. 

In an effort to explain the aggravation of symptoms in Trichomonas 
vaginalis vaginitis following the menstrual period, a series of com- 
parative cultures were studied. Simultaircously, subplants were made 
in which placenta agar slants were used as a base; Locke’s solution with 
5 per cent fresh human blood serum was added to one group, Locke’s 
solution with 5 per cent fresh human blood serum and 4 per cent 
progynon'^ (female sex hormone) was added to the second, and Locke’s 
solution plus 4 per cent progjnion to the third. Tubes from each of the 
three groups were inoculated with equal amounts of the same actively 
growing culture of Trichomonas vaginalis. At the end of twenty-four 
and forty-eight hours’ incubation at 37° C. comparisons were made by 
calculating the number of triehomonads per average high power field. 
It was observed that the addition of the progynon without the blood 
serum greatlj^ stimulated t!ie growth of the parasite; the addition of 
the progynon with the serum also stimulated it, but to a lesser degree. 
The third group in which Locke’s solution plus serum was used served 
as a control group. It v'ould seem from this experiment that the sex 
hormone content of menstrual blood may be a more important factor 
in causing the postmenstrual flare of Trichomonas vaginalis vaginitis 
than the presence of blood serum and possibly also of tissue fragments. 

STAINED PREPARATIONS 

Very little has been reported regarding the life cycle and the habits 
of Trichomonas vaginalis although the consensus of opinion is that 
reproduction occurs by binary fission (Lynch).’' To facilitate this study 
we used two stains. For fixed slides, Schaudinn’s solution was used 
as a fixative, followed by an iron hematoxylin stain. This was useful 
in studying the structure of the flagellate (Fig. 1). Variations in the 
size and shape of the nucleus of the parasite as well as indications of 
nuclear division were demonstrated. In some instances the relative 
shape and position of two flagellates indicated recent division, and what 
appeared to be budding forms were seen, but we are not able to draw 
any conclusions as to the life cycle of the parasite at the present writing 
(Pig. 2), 

For observing the activity of the living triehomonads, a 1-1000 
aqueous solution of a neutral red was utilized. The addition of a small 
drop of this solution to a hanging drop taken from a culture of living 
triehomonads stained the granules in the body of the parasite and em- 
phasized the cytoplasm, flagella and undulating membrane. The activity 
of the anterior flagella in whipping in food particles, bacteria, etc., ap- 
parently toward the undulating membrane and posterior flagellum was 
observe d. They also appeared to make way through the debris while 

Progynon was supplied by the Schering Corporation. 



824 


AMERICAN JOURNAL OP OBSTETRICS AND OVNECOLOOV 


the parasite accommodated itself to tlic available space b.v changing 
shape. The ameboid activity of tlie parasite was demonstrated and the 
facility with which it changed shape and sent out pseudopodia was 
surprising. The trichomonads became attached to bits of debris by 



Pig. 1. — Tricliomonas vaginalis from twelve-hour culture. Marked variation in size and 
shape ; apparent nuclear division. Iron hemato.vylin stain. 



Pig. 2. — Ti’icliomonas vaginalis from forty-eight-hour culture. Nuclear diA-ision, small 
forms, and apparent budding suggest reproduction. Iron hematoxylin stain. 


the axostyle and from this anchorage they rotated and changed shape 
rapidly. Precpiently the granules appeared to gather in the posterior 
end, while the antei’ior end of the flagellate became elongated. There 
was often a very decided narrowing in the center, sometimes becoming 
haiiiike, bnt in no instance was actual division seen. A resumption of 





STEIN AND COPE : TRICHOMONAS VAGINALIS 


825 


tlie normal pear shape from this dumb-bell shape was observed in some 
instances. "Wlieii motilit 3 ^ ceased, the trichomonads became round and 
the flagella seemed to fold around its circumference. Apparentlj'’ this 
indicated the death of the parasite. 

RESULTS 

Among 58 women with Trichomonas vaginalis vaginitis, trichomonads 
were found in the gums in 3, in the stools in 3, and in the catheterized 
urine in 5. It is apparent from tliis observation that there is no causal 
relationship between the vaginal incidence and that of other common 
sites of trichomonads in the bodjL There are cultural characteristics 
which differentiate the vaginal trichomonas from the buccal and intes- 
tinal types. While occasional instances of infection of husband and 
wife, and one case of infection of three female members of the same 
family are reported, the evidence is insuffieient to conclude that it is 
directly transmitted from person to person. 

The addition of female sex hormone to culture medium stimulated the 
multipheation of Trichomonas vaginalis in vitro. 

The source of trichomonads in the vagina is unknown. It is unlikeh' 
that thej’’ maj’' migrate from the other common sites in the body. 

We still support the belief that Trichomonas vaginalis is pathogenic 
ill the human being; that it is a specific species of trichomonas; that 
it is apparentty in symbiosis with the bacteria commonl}’' found in the 
vagina. 

We -wisli to acknowleCge our indebtedness to our colleagues in the Hospital, the 
Giuuc, and the Institute for materials and assistance, and to Drs. Frank Wright and 
Albert Zrunek for apparatus and assistance in obtaining motion pictures of the micro- 
scopic dark field. 

REFERENCES 

(1) Stein, I. F., and Cope, F. J.: Am. J. Obst. & Gynec. 22: 368, 1931. (2) 
Stein, I. F., and Cope, F. J.: Am. J. Obst. & Gyneo. 24: 348, 1932. (3) 
Frankenthai, L. E., Jr., and Koiak, A.: In print. (4) Fees, E.: Klin. Welmschr. 
10: 1176, 1931; 1223, 1931. (5) Bland, P. B., Wenlirich, J). E., and Goldstem, L.; 

Surg. Gjmee. Obst. 53: 758, 1931. (6) Bland, P. B.; South. M. J. 25: 17, 

1932. (7) Lynch, K. M.: Am. J. Trop. Med. 2: 531, 1932. 

310 South Michigan Avenue. 



ENDOMETRIAL HYPE RPLA SIA^- 
A RE^^Ew OP Experimental Work 

Lucius E. Burch, M.D., and John C. Burch, M.D., Nashville, Tenn. 

(From the Department of Obstetrics and Gynecology, Vanderbilt University School 

of Medicine) 

A n intensive study of endometrial hyperplasia has been in prog-. 

'• ress for the past three years in the laboratory and clinic of this 
institution. This paper is a brief summary of some of the results 
which have been obtained. Some of the results have been re- 
ported,®’ and others will be reported in the near future. 

The exact etiology of endometrial hyperplasia has not been deter- 
mined, but our results have shed some light on the question and have 
pointed the way to further research which is now in progress. Before 
discussing these findings, it seems desirable to review briefly the out- 
standing facts which serve to correlate the menstrual cycle of the 
human being with the estral cycle of experimental animals. 

Alleni has accurately described this cycle for the mouse. The uiimated mouse 
has a period of estrus every four to six days. At tlie time of estrus a characteristic 
change takes place in the vagina. This change consists in cornification of the 
vaginal mucosa, which is easily determined by means of smears. Ovulation takes 
place during the latter part of the estral phase, but the corpus luteum of the mouse 
remains inactive unless the animal copulates. tVhen the female is mated with a 
vaseetomized male, a stage of pseudopregnancy follows. This state of pseudopreg- 
nancy corresponds to that part of the human menstrual cycle lying between the 
time of ovulation and the onset of menstruation. Its main characteristic is a growth 
of the uterine mucosa, which, in the essential details, is similar to the human pre- 
menstrual endometrium. The time before the next estral period in the mouse is 
prolonged by pseudopregnancy from the normal four- to six-day interval to an 
eight- to fourteen-day interval. If copulation does not take place the corpus luteum 
is not activated and the uterus of the animal regresses from its estrus enlarge- 
ment and reaches a resting stage. Two to three days before estrus the epithelium 
becomes very active, the epithelial cells of the glands multiply, and numerous mitotic 
figures appear. There is definite pseudostratification of the epithelium and edema 
of the stroma. Occasionally mitoses are noted in the stroma cells. IVlien tlie 
pseudopregnant condition occurs, the gland cells lose their pseudostratified arrange- 
ment and become more regular. No mitoses are present at this stage. Therefore, 
in the mouse, we have two distinct phases, one before ovulation and one after ovula- 
tion. In the human female, following menstruation, the endometrium is of a low 
columnar tj-pe, no mitoses are present, and there is no secretion in the glands. In 
a few days a period of growth begins, the gland cells multiply, mitoses can be 
found and the mucosa increases in thickness. Ifollowing ovulation, a corpus luteum 
forms. In the human being this structure functions irrespective of the act of 

•Read at the Fourth Annual Meeting of the Central Association of Obstetricians 
and Gj-necologists, Memphis, Tenn., September 15-17, 1932. 

S26 



Burch and burch: endometrial hyperplasia 


827 


copulation. Following the formation of the corpus luteum, the endometrium in- 
creases in thickness, but its appearance and histologic characteristics are markedly 
changed. Numerous tufts or papillae project into the lumen of the gland. The 
glands gradually become more dilated, the nuclei assuming a more central position; 
there are no mitoses and no pseudostratification. The glands contain secretion. 
From this very brief description, it can readily be seen that the histologic changes 
occurring in the mouse are quite similar to those that are found in the human being. 

The estrus hormone, isolated by Allen and Doisy,^ and Frank,i5 and later puri- 
fied by Veler, Thayer and Doisy, 2 o when injected into spayed mice, causes the 
typical picture of estrus in the vagina and uterus. Allen and Corner^ have isolated 
another hormone from the corpus luteum, which when injected into the rabbit, pro- 
duces changes similar to those found in pseudopregnancy. They have been able 
to maintain pregnancy after the removal of the ovaries by means of this extract. 

Franki5 and Sinithas have shown that the estrus-producing hormone can be 
found in detectable amounts in the blood of human beings from about the four- 
teenth day until the time of menstruation. Parallel with this appearance of estrin, 
the corpus luteum becomes active and gives off its hormone. It is therefore fairly 
clear that the changes preceding ovulation are the result of the estrus hormone, 
and that the changes following ovulation are the result of the combined action of 
these two hormones. 

We have approached the problem of interpreting uterine scrapings 
from the standpoint of attempting to correlate morphologic changes 
with hormonie activity. Fluhman^^ has likewise vietved the problem 
from this angle. Hyperplasias of the endometrium have long been 
known to be the result of a disordered ovarian activity but it has not 
been possible to determine the exact type of this disorder from the 
examination of curettings. 

Schroder,^® Shaiv,-'^ Graves^® and others have made important con- 
tributions to this subject and have found that there are no corpora 
lutea in the ovaries of patients suffering from cystic glandular hyper- 
plasia, and that the ovaries of these women are generally cystic. It 
is apparent, of course, from this work that a disproportion between 
the two hormones, resulting in an excess of estrin, is a factor in the 
production of the pathologic picture. The logical inference is that 
hyperplastic changes are the result of the unopposed action of the 
estrus hormone. This is j^nrely a deduction and ivas tested experi- 
mentally in the following way Numerous histologic examinations of 
human endometria at the various stages of the menstrual cycle were 
niade. This material ivas compared with material from mice which 
had been injected with extracts of estrin and extracts of corpus 
luteum and with a combination of the two. Sections from 28 cases of 
Swiss-eheese hyperplasia were studied in the light of these compari- 
sons and wei’e found to be similar in many respects to the normal 
endometrium of the sixth to fourteenth days and to the endometria of 
animals which had received injections of estrin. The endometria from 
cases of human hyperplasia were max’kedly different, however, from 
the endometria of animals treated with mixtures of estrin and ex- 



828 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


tracts of corpus lutetim, aucl from the normal endometrium of the 
premenstiuial phase. These observations indicate that the cellular 
changes of human endometrial hjT^erplasia are the result of activity 
of the estrus hormone. HoAvever, in none of our experimental ani- 
mals were we able to produce the characteristic glandular dilatation 
seen in the human being. It was felt that, while the cellular changes 
were more important than the glandular dilatation, one must produce 
both in the same experimental endometrium in order to make a clear- 
cut demonstration. A further series of experiments was therefore un- 
dertaken in which a series of 24 spayed guinea pigs and 24 spayed 
rats were given varying amounts of estrin over a relatively long 
period of time.®^ Sections of the utei*i were removed at selected inter- 
vals during the injection period. A large percentage of guinea pigs 
which receded the estrin injections exhibited uteri in which the cel- 
lular and glandular picture was identical with that found in human 
hyperplasia. The glands, man.y of which were cystic, were very prom- 
inent throughout the greatly thickened mucosa. In rats we have 
found it more difficult to reproduce the typical Swiss-cheese pattern, 
although in 40 per cent of our animals the characteristic cystic dilata- 
tion of glands has been observed. 

The problem of studying the endometrium of patients with Swiss- 
cheese hyperplasia has been complicated by the fact that it is exceed- 
ingly difficult to obtain more than one specimen of tissue in any given 
cycle. In order to overcome this difficulty we have constructed a 
small metal cannula the size of a uterine probe whicli, when inserted 
into the uterus and attached to a syringe, upon A^dlich suction is made, 
removes sufficient tissue for histologic study.“’ This method of 
endometrial biopsy by suction has been exceedingly satisfactory from 
a clinical standpoint. We have obseiwed that many women bleed from 
an endometrium, which shows all of the characteristics of an estrin 
cellular reaction but which shows relativelj^ little glandular dilata- 
tion. These same patients in other cycles have shown glandular dila- 
tation. We feel that this is a clinical confirmation of the fact that the 
essential reaction is cellular rather than glandular. In view of these 
findings, the interpretation of uterine scrapings takes on an entirely 
different light. Any patient who bleeds abnormally from an endome- 
trium which shows no evidence of progestational proliferation is classi- 
fied by us as a case of endometrial lij^perplasia. In this broad sense, 
the teim endometrial hyperplasia is of course inadequate, as it simply 
indicates the pathologic end-result of an abnormal physiologic process, 
the intermediate stages of which are more common and just as impor- 
tant. One naturally asks the question as to how the endometrium of 
a patient suffering with endometrial hjTJerplasia is differentiated from 
that of one in the normal interval phase. This differentiation is ex- 



BURCH AND BURCH: ENDOMETRIAU HYPERPLASIA 


829 


ceedingly difficult from an. histologic standpoint and can only be made 
by establishing the fact that abnormal bleeding is coming from an 
endometrium which shows no progestational proliferation. This is 
best determined by securing tissue as near the onset of bleeding as 
possible. 

We have been impressed for a long time with the great frequency 
of abnormal bleeding following surgery upon the ovaries. In a recent 
series of experiments, rats were partially castrated.® These rats ran 
a very irregular estrus cycle with prolonged periods of estrus. Simi- 
lar observations had previousl3'’ been made by Haterius.^® The endo- 
metrium of these animals, which had a surgical ovarian deficiency and 
ran a continuous estrus, were veiy interesting from a histologic view- 
point. We have been able to obtain several typical examples of endo- 
metrial hyperplasia by this method, and we feel certain that the exces- 
sive removal of ovarian tissue in the human being predisposes to endo- 
metrial hyperplasia in later 3mars. 

Corneri® has found in monke5m (M. rhesus) that C3mlieal men- 
struation may proceed, at least for a limited time, without ovulation 
or the formation of corpoi'a lutea. We have some data obtained from 
biopsy specimens which indicates that this ma}’’ be true in women ap- 
proaching the menopause. 

The C3''clieal changes of the uterus are dependent on changes in the 
ovary, and these are dependent upon the secretion of the anterior 
pituitary. If, for any reason, the supply of the ovarian hormone (fol- 
liculiu-estrin) is decreased,®®’ ®’ -* degenerative changes in the uterus 
result. This degeneration manifests itself in the human being and 
in the monkey b3^ genital bleeding. If a corpus luteum is present it 
results from a progestational endometrium. If a corpus luteum is not 
present, the bleeding results from an interval endometi’iuin and if 
follicular stimulation has proceeded for a long period of time, the 
pathologic picture of endometrial h3'^perplasia may be present. If for 
only a short period of time, the endometrium may be of the normal 
interval tj'pe. The bleeding’ indicates endometrial degeneration, and 
ivill vary as to the degree and rapidity of the degeneration. There is 
evidence which indicates that the degeneration of a progestational 
endometrium is not similar to that of an interval endometrium. 

The essential factor, therefore, in the study of uterine bleeding is 
not the histologic state of the endometrium but the cause of the endo- 
nietrial degeneration which x’esults from a decline in estrin. 

In a previons paper we have called attention to the fact that the 
hypophysis affects the ovary, and the ovary, in turn, affects the 
h 5 q)oph 3 ’-sis.® The nature of this reciprocal relationship is being inten- 
sively studied at the present time and will be the subject of a later 
communication. 



830 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


Before dismissing tlie subject, however, we should like briefly to 
mention the following facts: (1) the ovarian stimulating capacity of 
the anterior lobe of the hypophysis varies according to the estral cy- 
cle, being highest in proestrus and lowest in early diestrus.=*“’ (2) 
Removal of the ovarian secretion as a result of castration increases 
the ovarian stimulating capacityd^ (3) Crude placental extract in- 
creases the ovarian stimulating capacity of spayed rats.® (4) Bstrin 
decreases the ovarian stimulating capacity of the anterior hypophysis. 
While the relationship is admittedly complex, it is nevertheless defi- 
nite, that the anterior lobe affects the ovaiy and the ovary affects the 
anterior lobe.-®> 

The cyclical nature of the menstrual function might well be the 
result of the proper adjustment of this relationship. The evidence 
indicates that endometrial hyperplasia is only an overgrown and ab- 
normally developed interval type of endometrium, from which patlio- 
logic bleeding results. Pathologic bleeding can result from a type 
which cannot be diffei'entiated from the normal. There is nothing in 
the histologic picture of these endometiua to suggest an especially 
marked tendency to hemorrhage. Occasional areas of degeneration 
are found which indicate the origin of some of the bleeding. The 
functional state of the endometrium is largely dependent on estrin, 
and an insufficiency of estiun causes the degeneration and the bleed- 
ing. The secretion of estrin is dependent on the stimulation of the 
anterior lobe. How this estrin affects the anterior lobe and causes a 
cessation of its stimulation is a question yet to be answered. 

The literature is full of many excellent articles on this subject. It 
is impossible to review them all. One article is of especial importance 
in this connection. Hofbauei*,®- by repeated injections of anterior lobe 
substance into guinea pigs, produced a definite experimental endo- 
metrial hyperplasia. He drew the conclusion that the condition was 
the result of the excessive stimulation of the anterior pituitary'. 
Pi'ankl,®® in a paper devoted exclusively to Hofbauer’s Avork, accepts 
overactivity as the factor in some cases, but thinks that congestion and 
inflammation of the OAmry are moi*e important. We believe that our 
expex’iments Avill do much to clear up the etiology of this condition 
and reconcile the divergent viexvs. 

The surgical and radiologic treatment of endometrial hyperplasia 
is well standardized at the present time. Either of these methods of 
treatment may be indicated following the failure of conservative 
treatment. Their indications have been repeatedly discussed. At the 
present time reports are appearing, indicating satisfactory results 
with injections of urinary hebin. This substance is the activator of 
the ovary in the Zondek-Aschheim test for pregmancj’’ and is made 
from human pregnant urine. It has been available for some time in 



BURCH AND BURCH: ENDOMETRIAL HYPERPLASIA 


831 


Germany under tlie name of Prolan. In tliis country satisfactory prep- 
arations are sold under the name of Autuitrin S., Pollutein.* The 
major portion of our work has been carried out with the former; in 
a small series of patients good results have also been obtained with the 
latter. 

The origin of urinary hebin has been ascribed to the anterior hy- 
pophysis. Recent work^“ casts some doubt on this origin, because 
urinary hebin is ineffective in the hypophysectomized animal and the 
amoimt of ovarian enlargement produced is proportional to the dose 
only to a certain point. After reaching this point we cannot get 
greater ovarian enlargement no matter how much is injected. Ante- 
rior hypophyseal hormone, on the contrary, gives an ovarian enlarge- 
ment which is proportional to the dose. The amount of enlargement 
of the ovaries when the two are given together is greater than the sum 
of their effects, and this difference is so great as to lead one to believe 
that there is a specific activation of the anterior pituitary sex hor- 
mone by urinary hebin. The source of urinary hebin is not definitely 
settled, but one should not forget that it is similar in many ways to 
the anterior pituitary like substance of the placenta. Goldstine and 
Pogelson^^ have obtained good x’esults in the treatment of uterine 
bleeding from injections of placental extracts and these were no doubt 
attributable to the anterior pituitary like substance of the placenta 
rather than to the estrin in the placental extract. 

Since the prolonged bleeding in endometrial hyperplasia is the re- 
sult of a degeneration of the endometrium, which in turn is a result of 
a deficiency of estrin, and which in turn is a result of a diminished 
secretion of the anterior lobe, it is of course apparent that any sub- 
stance that activates the anterior lobe and starts the secretion again 
will in turn activate the ovary and check the degeneration in the endo- 
metrium, and that when this is accomplished the bleeding will stop. 
On the basis of this conception we give antuitrin S. beginning at the time 
of the bleeding and continuing throughout, if we have reason to ex- 
pect that the bleeding is to be abnormal. If the patient is seen during 
bleeding, treatment is begun at once; if the bleeding has cheeked, 
treatment is postponed until bleeding recurs. "While the main action 
of extracts of urine of pregnant women is directly on the anterior 
lobe, there is some immediate action on the endometrium, as the bleed- 
ing IS very frequently increased for a time during the course of the 
injections. 

Engle,^^ in a recent publication, has called attention to a bleed- 
ing which occurs in monkeys during injections of extracts of urine 
preg nant women. The mechanism of this bleeding is unexplained 

to ^5® Indebted to Parke, Davis & Co. for a generous supply of antuitrin S., and 
■ -n. oquibb &s Sons for a generous supply of Pollutein. 



832 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


at the present time. The similarity to the increase noted Avith antu- 
itrin S. is suggestive. In developing this type of therapy it AAms felt at 
first that the injections of urine of pregnant Avomen Avould induce the 
formation of coi'pora lutea and that the presence of these bodies Avould 
regulate the disordered cycle. Geist/® hoAvever, Avas unable to pro- 
duce luteinization of the human ovary Avith therapeutic doses of this 
substance. Our oAvn experience-^ in studying biopsies of the endo- 
metrium after injections of extracts of urine of pi-egnant Avomen in- 
dicates that the formation of a progestational type of endometrium is 
not necessary to secure a satisfactory result. 

CONCLUSIONS 

1. The histologic changes iudicathm of endometrial hyperplasia are 
due to the action of the estrin hormone. 

2. Pathologic bleeding maj’’ I'esult from all stages of the estrin type 
of endometrium. 

3. The important diagnostic point is the determination of patho- 
logic bleeding coming from an interAml tjqie of endometrium. This 
can best be accomplished by obtaining tissue near the onset of bleed- 
ing. 

4. The removal of ovarian tissue predisposes to the development of 
endometrial hyperplasia in later years. 

5. Bleeding in endometrial hyperplasia cases results from a decline 
in estrin as a result of diminished anterior pituitary secretion. 

6. The hj'pophysis affects the ovary and the ovary aft’ects the 
hypophysis. The proper adjustment of this relationship has much to 
do Avith the periodicity of the cycle. 

7. In the final analysis, endometrial hj^erplasia is a disorder of this 
hypophyseal-ovarian relationship, resulting in abnormal and irregular 
declines in the amounts of estrin and anterior pituitary’' hormones 
aAmilable. 

8. Uriiiaiy hebin produces satisfactory results in the treatment of 
these cases. 

9. Its action is probably the result of anterior lobe stimulation. The 
cause of the increased bleeding during the injections and in the expe- 
riments of Engle is unexplained. 

10. It is not necessary to pi’OAmke luteinization of the OAmry and a 
progestational endometrium in order to secure good results. 

REFERENCES 

(1) Allen, E.: Am. J. Anat. 32: 293, 1923. (2) IMd: Am. J. Anat. 42: 467, 

192S. (3) Allen, E., and Eoisy, E. A.: Am. J. Physiol. 69: 577, 1924. (4) Allen, 

TF. M., and Corner, G. TV.: Am. J. Physiol. 88: 340, 1929. (5) Burch, J. G., and 

Cunningham, B, S.: Proc. Soc. Exper. Biol. & Med. 27: 331, 1930. (6) Burch, J. 

C., and Klingler, S.: J. Tenn. State Med. Assn. 25: 142, 1932. (7) Burch, J. G., 

TVilliams, TF. L., and Cunninqham, B. S.: Surg. Gynec. Obst. 53: 33S, 1931. (6; 

Burch, J. G., TVilliams, TV. L., TVolfe, J. M., and Cunningham, B. S.: J..A. M. A. 



BURCH AMD BURCH; ENDOMETRIAL HYPERPLASIA 


833 


97; 1859 1931. (9) Burch, J. C., Tl^olfe, J. M., and Cunningham, B. S.; Endocri- 

nology 18: 541, 1932. (10) Comer, G. TV.: J. A. M. A. 89; 1838, 1927. (11) Engle, 
E. T., and Smith, P. E.: Anat. Eecord 43: 239, 1929. (12) Evans, E. M., Meyer, 

K., and Simpson, M. E.: Am. J. Physiol. 1: 141, 1932. (13) Evans, H. M., and 

Simpson, M. E.: Am. J. Physiol. 89: 371, 1929. (14) Fluhman, C. F.: Surg. 

Gynec. Obst. 52: 1052, 1931. (15) Frank, B. T.: The Female Sex Hormone, 

Baltimore, 1929, Charles C. Thomas. (16) Geist, S. E.: Am. J. Obst. & Gynec. 
22: 935, 1931. (17) Goldstine, M. T., and Fo.gelson, S. J.: Am. J. Obst, & Gynec. 
21: 464, 1931. (18) Graves, TV. P.: Trans. Am. Gynec. Soc. 55: 234, 1930. (19) 

Saterius, E. 0.: Anat. Record 47: 318, 1930. (20) Klingter, E., and Burch, 

J. C.: J. A. M. A. 99: 559, 1932. (21) Klingler, E., and Burch, J. C.: Am. J. 
Obst. & Gynec. (in press). (22) Klingler, E., Burch, J. G., and Cunningham, 
B. S.; Surg. Gynec. Obst. 56: 137, 1933. (23) Leonard, S. L., Meyer, B. K., and 

Bisaw, F. L.: Endocrinology 15: 17, 1931. (24) Morrell, J. A., Powers, E. E., 

Varley, J. B., and Be Frates, J.: Endocrinology 14: 174, 1930. (25) Saiki, 

Seiichi; Am. J. Physiol. 10: 8, 1932. (26) Schroder, B.: Arch. f. Gynak. 98: 

SI, 1912. (27) Shaiv, Wilfred: J. Obst. & Gynec. Brit. Emp. 36: 1, 1929. (28) 

Smith, M. G.: Bull. Johns Hopkins Hosp. 41: 62, 1927. (29) Veler, C. B., 

Thayer, S., and Boisy, E. A.: J. Biol. Clrem. 87: 357, 1930. (30) Wolfe, J. M.: 

Am. J. Anat. 48: 391, 1931. (31) Wolfe, J. M., Camphell, Mary, and Burch, 

J. C.: Proc. Soc. Exper. Biol. & Med. 29: 1263, 1932. (32) Eofbauer, J.: Surg., 

Gynec. and Obst. 52: 227, 1931. (33) Frankl, 0.: Zentralb. f. Gynec. 55: 68, 1931. 

(34) Engle, E. T.: Proc. Soc. Exper. Biol, and Med. 29: 1224, 1932. 

2112 West End Avenue. 


Gyllensvard, N.: The Treatment of Eclampsia at the Stockholm Sud Maternity 

Hospital Prom 1911 to 1928, Acta obst. et gynec. Scandinav. 9: 221, 1930. 

The treatment of eclampsia in the cases reviewed was chiefly conservative. Among 
48,053 deliveries there were 282 cases of eclampsia (0.6 per cent). The total maternal 
mortality was 7.8 per cent and the entire fetal death rate 31 per cent. The maternal 
mortality for the eclampsia cases during pregnancy was 9 per cent, during labor 7.1 per 
cent and during the puerperium 8.3 per cent. Delivery was spontaneous in 40 per cent 
of the cases. Only 2 abdominal and 5 vaginal cesarean sections were performed. Vene- 
section is being used more and more and was employed in 71.4 per cent of the cases dur- 
ing the years 1924-1928. 

There were 1,149 cases of preeclampsia. Among 90 treated for more than twenty- 
four hours before delivery the maternal mortality was 4.4 per cent and the fetal death 
rate 30.2 per cent. Eclampsia developed in 8.7 x>er cent of the cases and delivery was 
spontaneous in 60 per cent. Among 59 cases treated less than twenty-four hours before 
delivery the maternal death rate was 6.7 per cent and the fetal rate 14.5 per cent. Spon- 
taneous delivery occurred in 79.7 per cent. 

Among 670 patients with nephropathy, 2.5 per cent developed eclampsia. Of 188 
treated for more than twenty-four hours before delivery 1.06 per cent died and of 482 
treated for less than twenty-four hours before deliverj- none died. 


J. P. Greenhile. 



/ 

/ 


A 

(From the Department of Ohstetrics, University of Tennessee) 

James R. Reinberger, M.D., Memphis, Tenn. 

S INCE roentgenologic examination lias become an integral part of 
tlie investigation for cases suggesting abnoi*malities, many more 
cases of obliquely conti-acted pelvis bave been reported. Nevertheless 
the paucity of the particular type of obliquely contracted pelvis here 
described is sufficiently marked to justify this detailed study. 

Mrs. L. S., -white, aged nineteen, gravida i, -^N'as admitted to the prenatal clinic 
of the University of Tennessee, June 1, 1927, about six months pregnant. 

The patient had had measles, mumps, and -whooping cough. In early life she 
-was told by her parents that physicians thought her left hip dislocated. She began 
to -walk at two years of age. At twelve years of age an attempt was made to 
straighten the left foot, which was markedly clubbed. Following this operation 
the application of a plaster cast resulted in gangrene. This in turn was followed 
by amputation of this leg in the lower one-third. The right foot was not as 
deformed as the left; but had several digits which gave considerable discomfort 
for about five years. Upon this right foot nine operations were performed to 
remove the extra digits, plus the attempts for straightening the moderately de- 
formed clubbed foot. At the age of fourteen years the last operation was per- 
formed for the removal of a bunion, and was followed by osteomyelitis. For some 
unkno-wn reason this necessitated amputation of the lower third of this right leg 
about one and one-half inches lower than that performed on the left. Following 
the amputation no further trouble was encountered. Artificial limbs have been 
worn constantly. 

Patient married two years. No precautions. Last monthly period Dec. 15, 
1926, date of confinement Sept. 22, 1927. 

The standing clothed individual presented no apparent abnormalities, except a 
slightly drooping left shoulder and a more prominent left hip. She walked -with 
no particular difficulty and certainly not to the extent that one would suspect 
her of using artificial limbs (Pig. 1). She stood in artificial limbs, which reached 
to the upper one-third of both extremities. Closer inspection from the front, 
revealed a marked tilt of the entire upper part of the trunk to the left side. Tlic left hip 
was decidedly higher than the right. Both hands were normal, except for an extra 
digit on the right thumb. From every view the position of the arms presented 
the form of a tight-rope walker -with a balancing pole. I assume that it was this 
same position of the a-rms which gave the patient some ease in standing or walking. 

It was ob-vious at once that the hair line of the mons veneris pointed to the 
left of the median line. The crotch -was held firmly together, possibly in an at- 
tempt to establish an equilibrium of the artificial legs. The skin surface presented 
no sears that would point to any old inflammatory lesion. 

From the back view of the patient (Pig. 1), the left hip was seen to be de- 
cidedly higher than the right. There was considerable left scoliosis. The but- 

‘Read at the Fourth Annual Meeting- of the Central Association of Obstetricians 
and Gynecologists, Memphis, Tenn., September 15-17, 1932. 

834 , . 


NAEGELE PELVI S WITH COINCIDENTAL D^ORMITIES 
OF GENITAL TRACT AND EXTREMITI!^ 



RKINBBEQEE: A NAEGELE PELViS 


835 


tocks were asymmetrical, the left being distinctly larger than the right. To 
account for this, there was a distinct protrusion beginning slightly to the left of 
the median line just above the junction on the two lips of the buttocks and 
extending to the body curve of the left iliac crest. This mass was firm, immovable 
and stood about 4 cm. above the body surface. It measured about 6 times 8 
cm. The shin surface, likewise, presented no sears. The removal of the artificial 
limbs revealed a bilateral amputation in the lower third of both legs. 

The thighs could be flexed and widely separated, showing absence of ankylosis 
of the hip joints. The vulva seemed unusually close to the narrow pubic arch. 
Separation of the labia majora revealed a vagina divided by septum which at first 



Fie. 1. — Front and back view, showing artificial limbs. Tilt of body. 


glance appeared to be transverse. In reality it was a well-formed, normal longi- 
tudinal septum, extending from the vulva to the cervices. The axis of the vagina 
had been rotated to the right to such a degree that one vagina in its lower third 
was superimposed upon the other, rather than parallel. Two distinct softened 
cervices were present. The right was infantile; the left, normal in size or maybe 
slightly hypertropliied, was on the pregnant side. The pubic arch was not vertical, 
hut was likewise rotated to the left so much so that if the diagonal conjugate was 
drawn from the promontory directly anterior, it would, strike the pubic bone about 
2 cm. to the right of the pubie arch. The transverse diameter of the outlet was 
slightly contracted and measured 7 :50 cm. The posterior sagittal was markedly 
increased due to the flaring out of the sacrum. The sacrum had lost its normal 
curve and was almost straight. The right iliopectineal line had a markedly exag- 



836 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOgY 


gerated pelvic curve, particularly of the ascending- ramus of the puHis. The left 
iliopectineal line extended straight back. The two sacroiliac joints revealed a firm 
synostosis. The left iliopectineal line shaded almost directly into the promontorj' 
of the sacrum. The real diagonal conjugate was shortened; but there was sufii- 
cient room in a 12 cm. false diagonal conjug-ate drawn from the promontory to 
the widest point in the curve of the right pubic bone. 

The pelvic measurements determined by roentgenograms were as follows: be- 
tween spines 26 cm., between crests 27 cm., external conjugate 22 cm., diagonal 
conjugate 9 cm., true conjugate 7 cm., left oblique 25 cm., right oblique 18 cm. 



Fig. 2. — X-ray showing the oblique deformity. Scoliosis to ieft or deformed side. 

Note the absence or hip joint disease. 

The special measurements advised in the original Naegele description are as 
follows: from tip of spinous process of last lumbar to left anterior superior spine, 
21 cm.; from tip of spinous process of last lumbar to right anterior superior spine, 
15 cm.; from center of sacrum to light sacroiliac joint, 7 cm.; from center of 
sacrum to left sacroiliac joint, 6 cm. 

The flat picture of the patient with the x-ray directed into the inlet (Fig. 2) in 
the sitting position gave the impression that the left iliac bone was atrophic, in 
that only one surface (anteroposterior) was evident. But realizing the extreme 
angle at which the ilium was placed to the middle of the pelvis, it became appar- 


REINBERQER: A NAEGELE PELVIS 


837 


eut that it was mipossible to show the inner surfaces of both iliac at the same 
time. This same flat picture showed that there wms an abnormal position of the 
sacrum and coccyx, both deviating with considerable curve to the left of the median 
line. The coccyx, however, was more angulated than was the sacrum. The left 
iliopeetineal curve was absolutely obliterated. The left innominate bone was dis- 
placed upward, backward, and inward. The left sacroiliac space was more dimin- 



Fig. 3. X-ray sacroiliac joints. Scoliosis to left side. Higher compensatory scoliosis 

to right. 

3shed than the right. The left ischial spine was distinctly closer to the midline 
of the pelvis and displaced upward. The left sacral ala was very much smaller 
than the right and was apparently firmly attached to the ilium. It could not be 
told from tins view whether the sacrum, ilium, and sacral ala were in direct apposi- 
tion. There wa.s haziness of the fifth lumbar vertebra, but nothing abnormal 
I’ould lie determined from this view. 



838 


AMERICAN JOURNAL. OP OBSTETRICS AND GYNECOLOGY 


The most outstanding point of interest in a lateral x-ray view of the pelvis 
was some definite osseous tissue wliieli apparently had no, or a questionable, con- 
nection with the body of the sacrum. This conforms with the protrusion men- 
tioned on the posterior surface of the left sacroiliac joint. The sacrum was 
straight and was flared out posteriorly. There was an additional malformation 
of the other sacral bodies in the form of a bifldsacrum. The last lumbar vertebra 
was deformed, but it was not clear enough to absolutely ascertain the exact defect. 

The x-ray of the spinal column revealed a marked compensatory scoliosis 
toward the left or a diseased side (Fig. 3). This scoliosis was further compensated 
by a higher one to the right side. The sacroiliac joint at tliis level cannot be 
studied. This plate was taken from the posterior surface of the body. 

The patient attended the clinic at regular intei-vals. She was free of any symp- 
toms and gained only twenty pounds. The blood pressure and urine remained 
negative. Wassermann was negative. It was decided to give this patient a chance 
at spontaneous delivery, as there was ample room on the right side of the pelvis. 

She was admitted to the hospital Sept. 18, 1927, with a history of having had 
regular pains with increasing intensity for twelve hours. The cervix was about 
one and one-half fingers dilated. The presenting part was not engaged. The 
x-rays revealed a moderate-sized baby with no cephalic engagement. The labor 
was terminated by a classical abdominal cesarean section under local and gas 
anesthesia. A male child (6 pounds 4 ounces) was extracted and breathed spon- 
taneously. The uterus was closed with two layers of interrupted No. 2 chromic 
sutures and a tliird continuous No. 2 plain inverting musculoperitoneal catgut 
suture. The uterus presented a distinct sulcus and a very much smaller right horn. 
The finger could not be passed into this smaller horn. Only one cervix could be 
palpated. 

Diagnosis . — A diagnosis of uterus septus with a double cervix and a double 
vagina was made. Tubes and ovaries were normal, as were, likewise, the round 
ligaments. The abdomen was closed. The patient nursed her baby and made an 
uneventful recovery and was discharged on the sixteenth day postpartum. She 
was reexamined at the six weeks ’ postpartum clinic, and when we confirmed the 
original findings, she was discharged. 

She was not seen again until Jan. 5, 1930, when she entered the Methodist 
Hospital about three months pregnant. Based on her physical and economic con- 
ditions, as well as a general debility, which had developed during the interim, I 
decided to terminate the pregnancy and sterilize. With proper consultation I 
terminated the pregnancy by abdominal hysterotomy Jan. 30, 1930, under local 
and gas anesthesia. To confirm my previous diagnosis, an incision was made into 
the nonpregnant horn which was in the same side as her previous pregnancy. The 
diagnosis was confirmed. Tubal sterilization was carried out by the Irving’s 
method. The patient made an uneventful recovery and was discharged on the 
tenth day postpartum. 

COMMENT 

I am still doubtful whether or not this pelvis could be classified as a true 
Naegele. Most textbooks and all articles discussing Naegele pelvis stress the fact 
that there is always absent the history of limp, difficulty in walking, hip joint 
disease, and moreover, many of the cases for this reason are overlooked as the 
majority deliver spontaneously. In this case there is a history of bilateral club 
foot. But the child walked at a fairly normal period of life. Likewise, because 
of the deformities of the extremities it cannot be said that these actually pro- 
duced the deformity of the pelvis, in so far as there are distinct deformities of the 
sacrum and lower spine. Even though this patient did have club foot, it is not 



REINBERGER: A NAEGELE PELVIS 


839 


unlikely that this pelvic deformity would have resulted from the defects in the 
body of the sacrum, the left sacral ala, and the lower lumbar spine. 

Aside from the inlet deformity which was typically an obliquely contracted 
obviate, there was a distinct pelvic outlet of the true Naegele’s form. The ver- 
tical axis of the pubic arch was rotated to the diseased side. The ischial spine 
was distinctly closer to the inidline of the pelvis, as was the iliopeetine'al line. 
In fact, the entire left half of the pelvis was in favor of a Naegele’s type, in 
that, the entire wall of the left pelvis was pushed upward, inw'ard, and backward 
on the diseased side. This was a contradistinction to a coxalgic pelvis resulting 
from hip joint disease in which the deformity was produced on the normal side 
to relieve the strain and weight of walking from the diseased side. The left leg 
was more deformed and caused more trouble in locomotion than did the right. 
If this were a coxalgic pelvis, the deformity should be found on the nonaffected 
side. 

Furthermore, the displaced backward and straight sacrum was of significance. 
If this deformity had its origin in rickets, sufficient to cause this marked dis- 
tortion, then you would expect a much more flared-out position of both ischial 
tuberosities. But such was not the case, because the pubic arch was actually nar- 
rower than a normal pubic arch. It must have resulted from compression inward 
by the weight of the body. I think the deformity of the sacrum resulted more 
from a malformation of the fifth lumbar vertebra. Furthermore, there was a low' 
lumbar scoliosis pointing to the diseased side, which was always characteristic of 
a Naegele’s pelvis. The second scoliosis simply compensated for the lower one. 
Dr. Williams, in his most excellent manner, reported a true case of Naegele’s 
pelvis in 1929. He was fortunate enough not only to examine his patient during 
life ; but also to obtain the pelvis at postmortem. Dr, Williams stated, ‘ ‘ that his interne 
overlooked his note of this deformity in her previous hospital history and also 
inferred that this oversight probably occurred from the fact that the patient had 
always had spontaneous deliveries in her six previous pregnancies. During this 
last delivery the tragic dystocia was encountered, wdrich necessitated version and 
manual extraction of the placenta. ’ ’ 

The absence in the history of any inflammatory process with the lack of evi- 
dence of gross bone pathology, absolutely rules out any inflammatory origin that 
might have resulted in this oblique contraction. Then if this be termed a Naegele ’s 
pelvis it is unquestionably not of inflammatoi'y origin. Those who insist that 
embryologic pelvic defects are the ■ etiologic factors, have their claim further sub- 
stantiated by the deformities of the sacral body, sacral ala and other associated 
deformities of the female generative tract, plus the deformities of the lower 
o.vtremities and the supernumerary digits of both upper and lower extremities. 
Furthermore, I am inclined to believe that this misplaced piece of bone posterior 
fo the sacrum is the undeveloped sacral alaj because it actually conforms in 
shape, size, and thickness to one or more segments of a normal sacrum. There- 
fore, in closing, I wish to repeat that while in certain particulars I have not 
keen able to satisfy myself that this is a true to form Naegele’s pelvis, yet it is 
allied. I am confident that this unusual type of oblique deformity is a primary 
embryologic defect and that the associated lower extremity deformities are purely 
coincidental. Gross examination of the pelvis could only decide the question 
of classification. 



THE TEST OF LABOR® 

Louis Rudolph, M.S., M.D., P.A.C.S., Chicago, III. 

(Attending Ohstetrician, Cool; County Hospital) 

'T'HE term “test of labor” has been vai-iously defined and has markedly 
different connotations among obstetricians at the present time. The 
criteria of the ‘ ‘ test of labor ’ ’ have not been standardized. This statement 
is borne out by the literature and particularly by the discussion -which f ol- 
lo-wed the paper by Harold Bailey^ at the 1926 meeting of the American 
Gynecological Society. Since the medical profession looks to the obstetric 
specialists to formulate the criteria of the “test of labor,” and since the 
“test of labor” so frequently predetermines operative interference -with 
its incident maternal and fetal morbidity and mortality, it is certainly de- 
sirable that the obstetricians define, or establish once for all the criteria of 
the ‘ ‘ test of labor. ’ ’ 

The “test of labor” has obviously both anatomieophysiologic and clini- 
cal aspects. This is true because the anatomy of the pelvis and of the fetus 
is concerned on the one hand, and the clinical picture of the mother on the 
other. Both aspects should be considered and properly evaluated, and 
one should not be emphasized at the expense of the other. The viewpoint 
of the present day obstetricians in regard to the criteria of the “test of 
labor” may be divided into two schools, namely, the “ anatomicophysio- 
logie ’ ’ and the ‘ ‘ clinical. ’ ’ Those who belong to the anatomieophysiologic 
group maintain that the “test of labor” should begin only after complete 
dilatation of the cervix, rupture of the membranes, and a given number 
of hours of ‘ ‘ second stage labor. ’ ’ Among those who have subscribed to 
these criteria are Schauta,- De Lee,® Williams,'* Edgar,® Cragin,® Holmes 
and Burdick," Bumm,® Kerr," Eden and Holland,*® Solomons,** Com- 
maudeur,*® Brouha,*® Goodall,*'* Beck,*® Danforth and Grier,*® Maxwell,’* 
and Longaker.*® 

Those who belong to the ‘ ‘ clinical school ’ ’ define the ‘ ‘ test of labor ’ ’ as 
a variable number of hours of ‘ ‘ strong pains, ’ ’ some taking into considera- 
tion the failure of the head to engage, and others the clinical condition of 
the mother or fetus. Bailey* writes, “The trial labor Avas conducted by 
alloAA-ing the patient to haA’^e tAA-eKe hours of strong pains AA’ithout vaginal 
or rectal examinations. If at the end of this time the head AA'as floating, a 
loAA" flap section aaus performed.” Lull*® states that if, “after a test of 
labor aAmraging eight hours, there is no attempt at engagement, section is 
done.” Hirst®® giA^es a primipara tAi'enty-four hours, and a multipara 
tAA’elA'e hours from the beginning of really strong labor pains. He AA'atches 

‘Read at the Fourth Annual Meeting of the American Association of Obstetri- 
cians and Gynecologists, Memphis, Tennessee, September 15-17, 1932. 

840 



RUDOLPH : THE TEST OP LABOR 


841 


the patient in regard to pnlse, temperature, and respiration, stating that a 
great deal of indiAddualization is required. Newell-^ writes that in some 
cases “a feAV hours’ trial Avill give a strong hint as to the probable out- 
come,” and again writes “of course the result of labor cannot be accu- 
rately predicted in a certain proportion of eases until the patient has had 
a true test of labor, i. e., Wo hours or more in the second stage of labor.” 
Stein and Leventhal-^ sum up the prevailing idea and their attitude in 
regard to a test of labor as folloAVS; “What constitutes an adequate test 
of labor is a matter of dispute and must be decided after a careful studj^ 
of each individual ease. ’ ’ Quigley-® uses a test of labor which varies from 
five to ninety-six hours. Laferts'®^ follows Tweedy’s method in which the 
maternal pulse and temperature (a rise above 100°) and the fetal heart 
tones (a rise above 160 or falls below 120 on three consecutive counts at 
one-minute intervals) are the chief criteria. Baer®® states that the crite- 
rion for a cesarean section is not complete dilatation of the cervix, but is 
dependent upon the experience of the obstetrician. Courtiss and Fisher®''’ 
indicate that their test of labor varied from one to one hundred and twenty 
hours. Kreis®' states that the test of labor may be limited to ten hours at 
the maximum after which time one can decide whether the labor will be 
terminated abdominally or vaginally. 

It appears that the number of hours the mother has been in “ineffective 
labor” is an important criterion to a number of those obstetricians who 
belong to the ‘ ‘ clinical school. ’ ’ I wi.sh to indicate and emphasize that the 
number of “hours in labor,” “hours of pains,” or “strong pains” is not 
an accurate criterion for a ‘ ‘ test of labor. ’ ’ Although the uterus may con- 
tract and produce a pain sensation, it does not folloAV that the contraction 
is effective in effacing and dilating the cervix, and in propelling the pre- 
senting part doAAmward. By analogy the gastrointestinal tract manifests 
tAvo types of motility, a propulsive and a nonpropulsh’e type. Contrac- 
tions may occur AA’ithout resulting in propulsion of the contents. Sim- 
ilarly the uterus may manifest these tAA’o types of motility. We knoAA’ that 
the uterus in labor is divided into the upper and the loAA’er uterine seg- 
ments AA’ith the ring of Bandl as a ridge dhdding the tAA’o. Normally this 
division of the uterus is dependent chiefly upon the upper segment, be- 
cause of its extremely significant jiroperty of isometric or sustained con- 
traction or shortening. This property of sustained contraction of the 
muscle fibers of the upper segment makes possible “retraction,” thicken- 
ing, or “capping,” and iirevents the loss of the advantage gained by each 
sustained uterine contraction. In other AA’ords the muscle fibers of the 
upper or active segment not only must contract, but must relax incom- 
pletely or manifest sustained contraction in order to bring about retrac- 
tion and the consequent effacement and dilatation of the cervix. During 
the first and second stage of labor the loAA'er or the relatively passive seg- 
ment must manifest the opposite property, namely, relaxation or the ca- 



842 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


pacity to be stretched. This difference in the functional motility of the 
two segments brings about the canalization of the cervix uteri. 

The first stage of labor or the opening-np of the loAver pole of the uterus 
is purely a mechanophysiologic process of the uterus itself. The fetus is 
relatively stationary during the first stage of labor,*' and the 

uterus per se brings about effaeement and dilatation of the cervical canal 
by the “uterine pull, ’ ’ which is exerted primarily on the cervix uteri. At 
the beginning of the second stage of labor the “uterine pull” is trans- 
ferred to the bony pelvis primarily through the attachments of the endo- 
pelvic fascia and the vaginal walls, Avhich is associated with the phenom- 
ena of “bearing-down.” With the onset of the second stage of labor the 
vaginal walls become taut, forming the uterovaginal canal. At this stage, 
descent of the ovoid begins, and proceeds as the upper segment becomes 
more and more thickened or “capped” with each succeeding uterine con- 
traction. Each uterine contraction is directly associated with a decrease 
in the uterine eavit5^ and a descent of the ovoid. 

These physiologic considerations of the uterus in labor suggest that we 
may be overestimating the importance of cephalopelvic disproportion, 
especially, if we do not give the head an opportunity to mold in the border- 
line eases. It is jiossible that many of our prolonged labors with floating 
or high heads are due to a disturbance of the physiology of the uterus in 
the first stage of labor. Physiologj’^ compels us to recognize that a dis- 
turbance of the properties of the upper and lower uterine segments is a 
factor that must be considered in our obstetric practice. 

What is the nature of this disturbance which lessens the effectiveness 
of the uterine contractions ? If the musculature of the upper uterine seg- 
ment does not manifest the normal phenomenon of isometric or sustained 
contraction on which retraction depends, the effectiveness of. the uterine 
contraction or “labor pains” is practically nil in that no thickening or re- 
traction of the ujDper uterine segment occurs, the ring of Bandl does not 
rise, the lower segment is not stretched or thinned, and an arrest in the 
canalization of the cervix uteri results. In other words, the uterine mus- 
culature may merely contract and relax. There may be no retraction. 
Consequently the normal physiologic changes in the uterus do not take 
place. This condition of uterine dysfunction may occur at any stage of 
labor. It may appear at the onset of labor (false labor), or the uterine 
contractions may begin normally, and then change to uterine d}’sfunetiou. 
Since in my experience uterine d3’sfunetion is practieallj^ alwaj's a tem- 
porary condition, I believe that cervical dilatation is the “barometer” of 
the phj'^siologic motor activity of the utex’us during the first stage of labor. 
The Schatz-Unterberger method which demonstrates the rising ring of 
Bandl determines usuallj^ the dilatation of the cervix and the ph3’siologic 
motor activity of the uterus. This concept of uterine dysfiuiction is im- 
portant, because in a case of prolonged labor with incomplete cervical 



RUDOLPH: THE TEST OP LABOR 


843 


dilatation and no eeplialopelvic disproportion, malposition, malpresenta- 
tion, previous section, or organic cervical pathology, it assures us that 
rupture of the normal uterus will not occur irrespective of the number of 
hours in labor. 

This presentation of the physiologic facts obviously supports the view- 
point of the ' ‘ anatomicophysiologie school” because it emphasizes the im- 
portance of the phenomena of isometric or sustained contraction, mani- 
fested by the upper uterine segment, and its relation to the formation of 
the uterovaginal canal. It should be obvious that the number of hours 
of “labor pains” does not necessarily represent effective uterine contrac- 
tions. It is necessary to differentiate between effective and noneffective 
uterine contractions, between true and false “labor pains.” The only 
differentiating point known at the present is the degree of effaeement and 
dilatation of the cervix, or the rising of the ring of Bandl. 

Whether the absence of the property of isometrie or sustained contrac- 
tion of the muscle fibers of the upper uterine segment per se is the sole 
cause of the uterine dysfunction, we cannot state, because its absence may 
be a part of the picture of incoordination between the upper and the lower 
uterine segments. This syndrome is indicated clinically by an arrest or a 
prolongation of effaeement and dilatation of the cervix. At the present 
time unfortunately, we have no drug or procedure with which to treat 
the musculature of the upper uterine segment when it fails to manifest the 
phenomenon of isometric or sustained contraction, the property of the 
uterine contractions Avhich renders propulsion of the ovoid possible. 

The author will avoid the use of statistics in general to demonstrate this 
point, because their interpretation depends so much on individual views, 
while fundamental principles are more important and lasting. However, 
in one phase of operative interference a brief generalization of statistics 
is pertinent to this discussion. In cesarean section the maternal mortality 
ranges from 2 to 25 per cent and higher. This does not take into consider- 
ation the resulting sterility and postoperative sequelae, the increased risks 
in future pregnancies and labors, and a fetal mortality which ranges 
from 4 to 30 per cent. With an increase in cesarean section, we must 
realize that as a result of undue haste in terminating labor, operative inter- 
ference per vaginum has, also, increased. We can only speculate con- 
cerning the statistics on this phase of operativerhiterf erence. It is possible 
that we may be able to decrease the incidence of operative interference by 
f oi'mulating and adopiting a safer and more rational ' ‘ test of labor. ” Less 
haste in terminating labor will result in greater saf etj^ for the mother and 
child. 

The “anatomicophysiologie school” has formulated a “test of labor” 
which is specific in its requirements. Where does the “clinical school,” 
the neu trend in obstetric thought lead us? It becomes necessary to deter- 



844 


AIMKRICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


mine whether or not its dicta are resiDonsible for the increase in operative 
interference. 

In all branches of medicine the basis of teaching should be the basic 
sciences, especially physiology. During the White House Conference on 
Child Health and Protection, Findley-® and ’ Arey®® emphasized the 
necessity of a better correlation between the teaching of the basic sciences 
and the teaching of obstetrics. Ehrenfest®^ writes, “Artificial delivery is 
becoming increasingly frequent, especially in hospital practice. One of 
the factors is an exaggerated idea of tlie value of the infant’s life, and the 
often false idea that artificial deliveiy is easier on the mother, incidently 
an idea which complies with the present demand of women for short 
labor.” 

The basic principles underlying the proper management of a parturient 
is the knowledge of the normal plysiology of the uterus in labor. When a 
disturbance of the physiologj'’ occurs avc should recognize the underlying 
changes clinically, and treat those changes conservatively in spite of the 
fact that our specific knowledge of the underlying etiology is scanty. The 
“clinical school” bases its “test of labor” upon the number of hours in 
labor, the subjective character of the pains, and the individualization 
without regard to the anatomicophysiologic conditions present. 

This viewpoint raises a number of interesting questions relating to the 
mechanism of labor based on mechanical and physiologic principles. 
(1) Why is the effacement and dilatation of the cervix prolonged in some 
cases? (2) Is the designation of labor pains as “weak” or “strong” of 
accurate clinical Amlue in a “test of labor”? (3) At what stage of labor 
does molding and compression of the head take place? (4) Why does the 
presenting part remain floating or high in some cases when no cephalo- 
pelvic disproportion, malposition, or malpresentation is present ? 

The first two questions are based on the physiology of a uterine contrac- 
tion. If during a uterine contraction the upper segment does not manifest 
sustained contraction or retraction, and the lower segment does not stretch 
or thin, the uterus is not performing physiologically. A labor pain is a 
subjective manifestation of a contraction of the uterus, and the subjective 
response of a patient to a labor pain depends upon the emotional state 
and the degree of sensitivity of the pain nerve endings in the uterus which 
may vaiy in different patients and in the same patient from time to time. 
To the author the designation of a labor pain as “weak” or “strong” is 
of neither clinical nor physiologic value. When the labor pain effects 
no progress in effacement and dilatation of the cervix,. it means that the 
upper segment is not undergoing retraction and that the lower segment is 
not stretching or thinning. This is designated as uterine motor dysfunc- 
tion, and explains the clinical phenomena. The author has pointed out 
above that the ‘ ‘ uterine pull ’ ’ in the first stage of labor is exerted chiefly 
on the cervix uteri, and is transferred to the bony pelvis in the second 



RUDOLPH ; THE TEST OP LABOR 


845 


stage of labor. It is at this stage that descent of the ovoid really begins, 
and that molding and compression of the fetal head occurs as it is forced 
to overcome the resistance of the inlet and the cavity of the pelvis by the 
normally contracting uterus. Even in cephalopelvie disproportion the 
physiologic progression of motor activity of the uterus cannot be disturbed 
markedly until the second stage of labor. 

In regard to the fourth question, it is Avell known that the presenting 
part may be floating or high during the first stage and early loart of the 
second stage of labor Avhether cephalopelvie disproportion is present or 
absent. Rudolph and Ivy““ have indicated that it is due to an incoordina- 
tion of the uterus in that the lower uterine segment is slow in forming, 
which is a temporary condition in the majoritj'' of instances. It is fre- 
quently true that floating or high heads with no cephalopelvie dispropor- 
tion are associated Avith prolonged labors. In the author's experience 
the expectant plan of management will result in the descent of the head 
and a successfully terminated labor an experience which has been reported 
by Harrar^^ and Carey and Casagrande.'’’^ 

If I interpret the viewpoint of the “clinical school" correctly, it is 
based solely upon extensive obstetric experience. Hirst,-® Stein and Lev- 
enthal,^^^ and Baer,-® stress the factor of individualization of each case and 
obstetric experience. Bailey,^ Lull,’^® Quigley,^® and Courtiss and Fish- 
er,-® base their ‘ ‘ test of labor ’ ’ upon a certain number of hours in labor 
and upon the character of the pains. Laferty®'* and others base the “test 
of labor" upon the maternal and fetal condition. A fact to be noted in 
the above references is that the authors quoted are obstetric specialists 
who have developed obstetric judgment. After extensive experience their 
judgment AA'ill undoubtedly take into consideration the underlying prin- 
ciples of the “ anatomieophysiologic school” in evaluating the indications 
for the management of a given ease. I do not question the obstetric judg- 
ment of the “clinical school.” But is their position fully justifiable? 
Should we not define the “test of labor” according to the “anatomieo- 
phj^siologic school” and add that only extensive obstetric experience per- 
mits the definition to be qualified ? Can Ave teach the ‘ ‘ clinical test of 
labor” to the undergraduate and the general practitioner? 

The physiologic considerations enumerated above do not conform Avith 
the criteria of the “clinical school,” because the normal and the abnormal 
states of the uterine contractions and the physiology of the first and the 
second stage of labor are not considered properly and evaluated. The 
subjective interpretation of a “labor pain” is no index of the underlying 
changes of the uterus. I believe, therefore, that the character of ‘ ‘ labor 
pains ’ ' cannot be used as a criterion for a ‘ ‘ test of labor. ’ ’ Normal uterine 
contractions bring about certain changes in the uterus that can be deter- 
mined relatively only on examination of the cerAux or by the Sehatz- 
Bnterberger method. This can be piwed by a study of frozen sections, 



846 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


and in cesarean section by the state of the upper and the lower uterine seg- 
ments, and the location of the ring of Bandl. 

Scientific obstetrics dates from Levret®* who in 1642 established the so- 
called ‘ ‘ obstetricomathematical school ’ ’ which fashioned obstetric thonght 
in a mechanical sense. It appears to me that we have overemphasized the 
importance of cephalopelvie disproportion when in reality the majority of 
our dystociae are due to the anomalies of the powers of labor or uterine 
dysfunction. In a recent paper, Wilson^® writes that disproportion is the 
reason usually given for performing cesarean section, when the cause may 
correctly be ascribed to imperfect functioning of the uterus, an opinion 
fully shared by the author. 'Williams’* Avrites that cesarean section should 
not be done in cases in Avhich the cause is due to an incoordination of the 
uterus. Although section may save the child, it will expose the mother to 
an unjustifiable risk. Cervical d 3 ’’stocia is a manifestation of uterine 
dj'sfunction, and Baudelocque,®" Cazeaux,**® and Hodge®® Avrote that no 
resort to artificial deliA'^eiy should be made in these cases ; Avliile De Lee'*® 
Avrites that cesarean section is justifiable in tliese eases after eight or ten 
hours Avithout cervical dilatation. 

For the purpose of teaching it appears to the author that the ‘ ‘ clinical 
school” attempts through their art, dcA^eloped bj' extensive experience 
to anticipate Avhat may occur, instead of giving the medical profession 
definite criteria on AA’hich to base a ‘ ‘ test of labor. ’ ’ In teaching obstetrics, 
the author is firmlj'- couAdnced that Ave should be uniform and teach the 
basic principles underlying the “ anatomicophysiologic school’s” defini- 
tion of a “test of labor,” The criteria of the “clinical school” should be 
reserA’^ed for the obstetric specialist aa'Iio has gained obstetric judgment. 
This is exemplified by De Lee® who in his textbook adheres to the definition 
of the “anatomicophj^siologie school,” Avhich is intended as a guide for 
the student and the general medical profession, but Avho in his OAvn prac- 
tice maj'^ determine a “test of labor” based on his obstetric judgment.'** 
LulB® has recentl}^ expressed this aucav by stating that the undergraduate 
should be taught the most conservative tj^ie of obstetrics, AA'hile the ob- 
stetric specialist may be governed by his obstetric judgment. The medical 
profession is influenced greatly by the lectures and publications of the 
obstetric specialists and teachers and too frequentlj^ folloAV a method or 
opinion that has been developed and used only after years of specialized 
experience. 

The author is of the opinion that if the anatomicophj^siologic criteria of 
a “test of labor” only are taught and due emphasis placed upon them in 
all papers on the subject, there Avill result a decrease in the incidence of 
operative interference and a corresponding decrease in the maternal and 
fetal morbidity and mortality. The indication in the main for cesarean 
section should be determined as a primarj’- operation before the onset of 
labor, as was emphasized by Grandin'*-® and Re.Amolds.'** During the pre- 



RUDOLPH: THE TEST OP LABOR 


847 


natal period a study of the stature of the patient and pelvimetry gives 
us a relative idea of the pelvis. From the thirty-sixth to the fortieth week 
of pregnancy the cephalopelvie relation may be determined by the impres- 
sion methods of Muller-Pinard, Monroe Kerr, and Hillis, which if neces- 
sary may be carried out under anesthesia. Before the onset of labor a 
diagnosis should be made on the manner of delivery based upon an abso- 
lute, a relative disproportion, or a normal cephalopelvie relation. During 
the course of labor the functional activity of the uterus should be diag- 
nosed as normal or uterine dysfunction. 

In the presence of a diagnosis of an absolute disproportion and of a 
normal cephalopelvie relation, the indications for the management are 
definite. In the presence of a relative disproportion or in a “border-line” 
case, it becomes necessary to evaluate the conditions present and to de- 
termine the method of delivery, abdominal or vaginal. If the vaginal 
route is elected, then in the majority of instances the abdominal route is 
closed, and the patient is given a “test of labor” which may be terminated 
by forceps, pubiotomy, cesarean section, or craniotomy ; and occasionally 
by either a Porro or Portes cesarean section. This method of management 
by the medical profession, Avill I believe generally be safer for the mother 
and child, except the craniotomy on the child. In the majority of border- 
line cases, we should not consider deflexion attitudes as a mechanical re- 
sult. Rudolph and Ivy*® have indicated that the deflexion attitudes and 
arrested or prolonged internal anterior rotation of the presenting part are 
primarily due to an incoordination of the uterus ; so even if this occurs in 
a given case, it may be corrected in the second stage of labor by manual 
or forceps reposition or by an early version and extraction. 

Exhaustion is frequently stressed as a complication in prolonged labor.s 
due to uterine dysfunction. The author is firmly convinced that exhaus- 
tion is most often due to improper management of the parturient. Ex- 
haustion is caused by either psychical or physical factors. If the patient 
is prepared for the ordeal of labor and her physical condition properly 
treated by periods of rest and a normal intake of food and liquids for each 
twenty-four hours of her labor, particularly in a so-called “test of labor” 
when the prolonged labor is due to uterine dysfunction, exhaustion wdll 
be infrequent in occurrence. 


SUMMABT 


1. The “test of labor” is an important and fundamental obstetric term 
based on definite physiologic changes in the uterus and should be 
thoroughly understood by the novitiate in obstetrics. 


2. The diagnosis and management of the border-line cases of cephalo- 
pelvic disproportion should be taught thoroughly to undergraduates at 
die expense of some of the more highly technical and specialized methods 
for operative interference. 



848 


AMEBICAN JOURNAL OF OBSTETRICS AND GYNECOLOQT 


3. The ‘ ‘ anatomicophysiologie” definition of a “test of labor’ ’ should be 
accepted as a standard definition to be qualified and departed from in 
practice only by the obstetric specialist who has gained obstetric judgment 
after an extensive experience. 

4. The statistics on operative interference reported by obstetric special- 
ists do not indicate the correct morbidity and mortality, because most 
cesarean sections are performed by general surgeons. By reason of his 
personal influence and progressive ideas, Mosher^® has pointed the way 
out. He has succeeded in convincing the general surgeons in his com- 
munity to consult the obstetric specialist for the indication for cesarean 
section. 

5. In the eapaeitj'^ of obstetric specialists and teachers it will be to the 
advantage of our womanhood, if we impress upon the undergraduates and 
the medical profession generally the fact that the proper time for obstetric 
consultation is before the onset of labor. 

REFERENCES 

(l)Bailey, E.: Am. J. Obst. & Gynec. 12: 550, 1926. (2) Schauta: Quoted by 

J. C. Litzenberg: Am. J. Obst. & Gynec. 12; 598, 1926. (3) DeLee, J. B.: The Prin- 
ciples and Practice of Obstetrics, ed. 4, 1926, Philadelphia, W. B. Saunders Co. (4) 
Williams, J. IF.; Obstetrics, ed. 5, 1926, New York, D. Appleton and Co. (5) Edgar, 
J. C.: The Practice of Obstetrics, revised by Norris W. Vaux, 1926, Philadelphia, P. 
Blakiston’s Son & Co. (6) Cragin, B. B.: Obstetrics, 1926, Philadelphia, Lea & 
Pebiger. (7) Holmes, E. W., and BurdicTc, A. L.: Am. J. Obst. Sc Gynec. 6: 597, 1922. 
(8) Bumm, E.: Grundriss zum Studium der Geburtshilfe, 1902, Wiesbaden, J. P. 
Bergmann. (9) Kerr, J. M,: Operative Midwifery, 1916, London, Bailliere, Tindall 
and Cox. (10) Eden, T. W., and Holland, E.: A Text-Book of Obstetrics, ed. 6, 1925, 
New York, The Macmillan Company. (11) Solomons, B. : J. Obst. & Gynec. Brit. Emp. 
36: 1929. (12) Gommandeur, F.: La Pratique de I’Art des Accouchements 11: 249, 

1914. Edited by P. Bar, J. Chambrelent and A. Brindeau. Asselin et Houzeau, Paris. 
(13) Brouha, M. : Eev. Pranc. de Gynec. et d’Obst. 25 : 449, 1930. (14) Goodall, J. B. : 
Am. j. Obst. & Gynec. 12: 597, 1926. (15) Beclc, A. C.: Am. J. Obst. & Gynec. 6: 
623, 1922. (16) Banforth, W. C., and Grier, B. M.: Am. J. Obst. & Gynec. 16: 239, 
1928. (17) Maxivell, A. F.: J. A. M. A. 89: 2088, 1927. (18) Longaher, D.: Am. J. 
Obst. & Gynec. 17: 1929. (19) Lull, C. B.: Am. J. Obst. & Gynec. 17: 404, 1929. 
(20) Hirst, B. C.: Pers. Com. (21) Newell, F. S.: Monograph on Caesarean Section, 
1921, New York, D. Appleton and Company. (22) Stein, 1. F., and Leventlial, M. L.: 
Am. j. Obst. & Gynec. 16: 229, 1928. (23) Quigley, J. K.: Am. J. Obst. & Gynec. 
17; 597, 1929. (24) Laferty, J. M.: Am. J. Obst. & Gynec. 19: 647, 1930. (25) 

Baer, J. L.: Am. J. Obst. & Gynec. 20; 425, 1930. (26) Courtiss, if., and Fisher, 

J. C. r.: Am. j. Obst. & Gynec. 23: 679, 1932. (27) Kreis, J.: Gynec. et Obst. 23; 
385, 1931. (28) Beynolds, E.: American Text-Book of Obstetrics, 1896, Philadelphia, 
W. B. Saunders. (29) Findley, P.: Am. J. Obst. & Gynec. 21: 783, 1931. (30) Arey, 
L. B. : Am. J. Obst. & Gynec. 21 : 880, 1931. (31) Ehrenfest, H. : Am. J. Obst. & 
Gynec. 21: 867, 1931. (32) Budo^ph, L., and Ivy, A. C.: Am. J. Obst. & Gynec. 21: 
65, 1931. (33) Harrttr,J.A.; Am. J. Obst. & Gynec. 5 ; 246, 1923. (34) Carey, W.H., 
and Casagrande, J.: J. A. M. A. 84: 888, 1925. (35) Levret, M. A.: L’Art des Ac- 
couchements, ed. 3, 1761, Paris, Pr. Didot, Le Jeune. (36) Wilson, J. St. G.: J. Obst. 
& Gynec. Brit. Emp. 38: 504, 1931. (37) Baudelocque, L.: A Sj'stem of Midwifery, 

translated by John Heath, 1790. J. Parkinson and J. Murray. (38) Caseaxix, P., and 
Tarnier, S.: The Theory and Practice of Obstetrics, ed. 8. Revised by E. J. Hess, with 
appendix by P. P. Munde, 1, 1886, Philadelphia, P. Blakiston’s Son and Company. 

(39) Hodge, H. L.: Principles and Practice, 1864, Philadelphia, Blanchard and Lea. 

(40) DeLee, J. E.; J. A. M. A. 89: 2092, 1927. (il) BeLee, J. B.: Pers. Com. (42) 

Lull, C. B.: Am. J. Obst. & Gynec. 24: 75, 1932. (43) Grandin, E. H.; Am. Gynec. 

Trans. 15; 382, 1890. (44) Beynolds, E.: Am. Gynec. Trans. 32: 43, 1907. (45) 

B\idolph,L.,andIvy,A.C.: 25: 74, 1933. (46) if oslier, G. C.: Surg. Gynec. Obst. 45 : 
655, 1927. 

55 East Washington Street, 



--'I 

FURTHER STUDIES IN THE XRB^^L^T OP PUERPERAL 
S^™EmA(AND] OTHER BLOOD''sTREAM ^SEO^NS c.^ 
I WITH META raEN 

J. B. Bernstine, M.D., P.A.C.S., Philadelphia, Pa, 

(From the Department of Obstetrics Jefferson Medical College) 

N otwithstanding tlie great strides that have been made in 
the treatment of disease, septieemia continues to exact an ap- 
palling toll of morbidity and mortality. Thus, according to the fig- 
ures quoted by Bland,^ who has made a careful study of the maternal 
death rate, the maternal deaths recorded in the registration area in 
the United States alone during the period from 1915 to 1926 inclusive 
aggregated 174,385, and of this number 70,746 died of septieemia. If 
to these figures are added the deaths resulting from septicemia not 
due to obstetric causes, in children as well as adults, the seriousness of 
the problem will be fully realized. 

While many drugs and methods of treatment have been used, none 
has proved to be entirely effective. The chemotherapeutic mode of 
attack has chiefly centered around attempts to find a drug which 
would destroy the offending organism in the blood stream. It has 
been pointed out by Kilduffe,^ hoivever, that the bacteriostatic action 
of the drug introduced into the blood stream may be at least as im- 
portant as its bactericidal effect. In order to understand the reasons 
for this thesis, one must consider the various factors underlying a bac- 
terial infection of the blood stream. It is common knowledge that an 
initial focus is always present in such infections. The invading or- 
ganisms enter the blood stream from this focus intermittently,- thus, 
according to Trout,® the peripheral circulation may be entirely free 
from bacteria which are, nevertheless, at the same time present in 
large numbers in the spleen, livei”, and bone marrow. It is, therefore, 
possible for peripheral blood cultures to change from negative to posi- 
tive within a few hours ; this situation is usually described by saying 
Uiat the bacterial invasion takes place in ' intermittent “showers.” 
Further, the importance of the natural defenses .of the organism must 
be emphasized; these include filtration bj'- the Ij’-mph glands, forma- 
tion of antibodies, and phagocytosis. 

It is argued by Kilduffe, therefore, that greater wmight should be 
placed on the bacteriostatic properties of drugs intended to combat 
septicemia; for it is doubtful -whether a bactericidal agent can ever 
be found of such low toxicity that a quantity sufficient to destroy all 
the microorganisms present could be safely introduced into the blood 


849 



850 AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 

stream ; on the other hand, a much smaller quantity of a chemical com- 
pound may be bacteriostatic, i.e., it will inhibit the growth and activ- 
ity of bacteria in the blood stream, and thus reinforce the defensive 
mechanism of the organism sufficiently to overcome the infection. 

It was, therefore, natural to consider metaphen in this connection 
because of its high bacteriostatic action, as found by Raiziss and 
Severac*' ® and Birkhaug." A desci'iption of the chemical composi- 
tion and the properties of this compound may be found in a previous 
article by me.® Sixteen eases were then reported; the results were 
very favorable, and marked tolerance of the dnig was noted. There 
was no evidence of renal or gastrointestinal irritation, frequently ob- 
served with intravenous mercurial dye therapy. The present paper 
contains a report on further eases of intravenous treatment with meta- 
phen of bacterial infections of the blood stream of various types. 

The drug was also used successfully by the ■ intravenous route, by Spotts,o 
Pisher,io DuBois,ii Bledsoe .12 More recently Keeleris reports an interesting case 
of septicemia due to Staphylococcus aureus, in which metaphen was given intraven- 
ously with most gratifying results. Hii-sehfelder and Wrighti^ in their study on 
the colloid chemistry of antisepsis and chemotherapy, report that metaphen shows 
no evidence of any colloidal particles under the ultramicroscope, and this observa- 
tion is further confirmed by the fact that the preparation dialyzes completely and 
rapidly. It does not produce any noticeable changes in the ultramicroseopio ap- 
pearance either of egg albumen or plasma, and it seems, therefore, that metaphen 
should show but slight tendency to produce anaphylactoid reactions upon intravenous 
injection. Levinson and Perlsteinis studied the effects of intrathecal administration 
of mereurochrome-220 soluble and of metaphen, and arrived at the following con- 
clusions: “Metaphen deserves further investigation as an intrathecal disinfectant, 
for not only does it have a larger margin of safety than mercurochrome, but it is 
bactericidal in sublethal doses.” 

In dealing with blood sti'eam infections, it is of great importance 
to formulate a definite procedure with respect to the taking of blood 
cultures, and to adhere to it strictlj^ in all cases, so that a systematic 
study may be made of the gTowth and habits of the invading organ- 
ism. In my opinion blood cultures should be taken as soon as the 
initial chill and the sudden and marked rise in temperature occur, and 
one should not wait until bacteremia has existed for several days. The 
cultures should be repeated, if at first negative, for often a positive’ 
result is obtained only after repeated attempts. Care should also be 
taken that cultures are not reported negative too soon, and then dis- 
carded. It has been my experience that if cultures are allowed to 
incubate for several days the number of positive cultures is increased. 
Some observers have recommended an injection of adrenalin before 
taking a culture. This procedure is believed to increase the number 
of positive findings ; however, at present I am not prepared to venture 
an opinion on this point. 



BERNSTINE : PUERPERAL SEPTICEMIA 


851 


It is a matter of prime importance to institute treatment at tlie first 
suspicion of septicemia, without waiting for tlie results of the culture. 
If the condition should turn out to he something else, it is unlikely 
that the patient will have suffered from the treatment, while if the 
suspicion of septicemia is confirmed, promptness in instituting treat- 
ment may turn out to be the decisive factor in saving the patient. 

The method of treatment, described below, has been followed on 
all patients with very few modifications. As soon as the diagnosis is 
made, or whenever a suspicion of septicemia arises, an initial intra- 
venous injection of metaphen 1:1,000 is given. The usual dose is 10 
c.c. for the average adult; smaller doses are given to children and 
very old persons. It is not unusual to give an initial dose of 20 c.c. 
and even with this dose reactions are infrequent. In our previous 
paper certain points in connection with the administration of the in- 
travenous injections of metaphen were mentioned which it is well to 
bear in mind (the use of a small gauge needle and the slow injection 
of the drug). The injections may be safely repeated every other day, 
for some of our patients have received injections daily without any 
untoward effects (as e.g., renal irritation, jaundice or gastrointestinal 
irritability). As has been mentioned before, should it turn out that 
the patient has not true septicemia, no harm will have been done ; in 
fact, the drug seems to act prophylactically in such cases. At the 
same time, it should always be borae in mind that in cases of sep- 
ticemia the sooner treatment is instituted the greater are the chances 
for recovery. 

In addition to this treatment we have also used glucose 25 per cent, 
120 c.c. daily; ingestion of alcohol is of considerable value. Other 
drags, such as digitalis and strychnine were used whenever needed. 
Plenty of fresh air and sunshine are necessary, and attention to oral 
hygiene is of paramount importance. 

In our series of cases we have found whole blood transfusions of 
considerable value. From 100 to 250 c.c. of blood were given everj’’ 
other day, obtained if possible from a different donor each time ; the 
transfusion is performed when the patient’s temperature is at the low- 
est level. The transfusions should be performed without moving the 
patient from his room and his bed. 

Ir summing up our treatment of septicemia, we may emphasize the 
following factors : Most cases of septicemia follow surgical procedures, 
an aboi’tion or cliildbirth, an acute or chronic sinus infection, or- an in- 
fection of the same sort in the male genitals or female pelvis; a sore 
throat, otitis media, or an apparently trivial superficial external wound ; 
m a minority of cases the original focus cannot be detennined. What 
orgamc involvements are to supervene cannot be predicted in the be- 
ginning; endocarditis, suppurative arthritis, and embolic phenomena 



852 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


are frequent. Some patients die verj^- quickly from an over-wlielming 
toxemia, others may linger only to succumb after several weeks or 
even months. The mortality has been placed as high as 60 to 80 per 
cent, according to Tileston,^® and 70 to 90 per cent, according to Her- 
rick.^^ Beckman^® states that “when the prognosis is considered. in a 
given case the following factors have to be seriously evaluated : (1) 

Variety of the organism, (2) volume of the organism, (3) virulence of 
the organism, and last hut of considerable importance is the vital re- 
sistance of the patient.” 

We now present several tj'pieal cases to illustrate the results ob- 
tained : 

Case 1. — F. L., aged tldrty-six, widow, onset, one week previous to admission to 
the hospital, with symptoms of an upper Tespiratorj- infection (fever, coiyza, and 
cough). 

Three daj's later (Dee. 4, 1931), the patient had a severe chill, and a severe 
lancinating pain developed in the right lower quadi'ant, pointing to the region of 
the bladder. On examination, the tongue was furred, the teeth were in good con- 
dition, the pharj'nx was slightly injected.- The nasal mucous membrane was 
engorged. 

Chest examination: The breath sounds were harsh, and an occasional crackling 
rale was heard at the right base, posteriorly, but no dullness was elicited. 

On examination the heart was found to be normal. 

Abdominal examination: On palpation, extreme rigidity was found in the 
right flank and right lower quadrant, the area of rigidity being extremely tender. 
Strangely enough, at no time was there any urinarj' disturbance. 

Blood count on Dec. S, 1931, showed- the- following: Hemoglobin 50 per cent; 
red blood cells 3,450,000; white blood cells 10,900. The urine was acid in reaction 
and showed a trace of albumin; there was a large amount of pus. 

The temperature was 103° F., pulse 110, respiration 26. On Dec. S, 1931, 
pyelographic studies were made and the diagnosis of stone in the right ureter was 
made. The location was given as about 8 cm. along the right ureterovesical 
orifice. The urine was cultured and a pure culture of B. coli communis was obtained. 
The patient’s temperature, in spite of various forms of medication, ranged from 
98° and 99° F. to 104° and 106° F. The pulse and respiration were correspond- 
ingly accelerated. The patient was having repeated chills and was rapidly losing 
ground. A blood culture was taken and on Dec.- 14, 1931, a pure culture of B. 
coli communis was obtained. The patient was running a septic temperature from 
Dec. 4, 1931. 

Finally, I was consulted and advised metaphen 1:1,000 intravenously. There 
were 10 c.c. given on Dec. 19, 1931. There was no reaction, and 10 e.c. were 
given on Dec. 21, 1931; on Dec. 22, 1931, the temperature reached normal and 
continued normal until the patient’s discharge from the hospital on Jan. 8, 1932. 
Another culture which was taken on Dec. 30, 1931, was reported negative after 
several days of incubation. 

The patient’s physician informed us almost two and one-half months later that 
she was enjoying good health and did not have any recurrence of her former 
symptoms. 

Case 2. — Patient S., aged forty-seven, was admitted to the hospital on June 11, 
1931. Diagnosis on admission was otitis media, arthritis, and septicemia. A blood 
culture was taken on the eleventh. On the thirteenth of the same month, a growth 



BEENSTINE : PUERPERAL SEPTICEMIA 


853 


of streptococcus was obtained, wliicli, on the fifteenth, was shown to be Streptococcus 
hemolyticus. On the sixteenth, the blood was still positive for Streptococcus 
hemolyticus, and remained so until the twenty-sixth of June. Then it became 
negative and remained negative. 

The blood count on the twelfth of June was as follows: Hemoglobin 87 per cent; 
red blood cells 4,400,000; white blood cells 18,000; polymorphonuclear cells 78 per 
cent; lymphocytes 22 per cent. On June 18, hemoglobin 75 per cent; red blood 
cells 4,000,000; white blood cells 13,400; polymorphonuclear cells 89 per cent; 
lymphocytes 11 per cent. On the twenty -fourth, hemoglobin 69 per cent; red blood 
cells 3,000,000; white blood cells 19,000; polymorphonuclear cells 88 per cent; 
lymphocytes 12 per cent. On July 15, hemoglobin 70 per cent; red blood cells 
3,000,000; white blood cells 16,800; polymorphonuclear cells 71 per cent; lympho- 
cytes 11 per cent. 

The temperature was high for several rveeks and of a hectic type. The patient 
had a suppurative arthritis of his knee which was incised and drained. During 
his illness, the patient received six injections of metaphen intravenously, of 10 c.c. 
each. The patient made an uneventful recovery. Ankylosis of the knee developed 
which, it is hoped, will be only temporary. 

Case 3. — ^N. D., aged thirty-two, female, wdiite, four children living and well, 
admitted to the hospital on Feb. 13, 1931. Chief complaint, pain in lower abdomen 
and chills; somewhat nauseated. Last menstrual period, Dec. 8, 1930; amenorrhea 
during January and February. Examination revealed systolic mumur at apex 
transmitted to anterior axillary border. Temperature was 102° F., pulse 120, blood 
pressure 88/60. The blood count was as follows: Hemoglobin 60 per cent; red blood 
cells 3,307,000; white blood cells 7,200; polymorphonuclear cells 76 per cent; 
lymphocytes 24 per cent. There was moderate abdominal distention, and the spleen 
was markedly enlarged. Pelvic examination revealed a pregnancy of third month. 
There was no uterine bleeding. On February 14, a three-month fetus was expelled, 
but part of the placenta was retained. Patient had a chill, temperature rising to 
104° P., and pulse reached 145. On February 18, some blood clots were passed 
and part of the placenta. The blood culture was positive for Streptococcus 
hemolyticus. 

On February 19, the patient was given 10 c.c. of metaphen 1:1,000 intravenously; 
no untoward reaction. On February 23, she received 250 c.c. whole blood trans- 
fusion, and on the twenty-sixth, the temperature reached 106° F. Ten cubic centi- 
meters of metaphen were given intravenously^, also on February 27, and 1 c.c. of the 
patient’s vaccine, containing a half million organisms in each cubic centimeter, was 
given to the patient. On March 2, the patient was feeling much better. On 
March 12, culture was negative, the patient was up and about and she was gaining 
weight. Spleen was no longer palpable. She was discharged in good condition on 
March 30. 

Case 4. — ^R. D., female, aged thirty-one, was admitted to the hospital on April 
16, 1931. Last period, March 6; she missed the April period. The patient per- 
sonally inserted a stick of slippeiy elm into the cervix and up into the uterus. 
Bleeding soon followed, accompanied by uterine contractions and pain. There was 
also elevation of temperature. On admission, the patient’s temperature was 105° F., 
pulse 135, respiration 30; the blood chemistry was 98, and the blood count was as 
follous: red blood cells 3,500,000; white blood cells 21,100; polymoi'phonuclear 
cells 89 per cent; lymphocytes 10 per cent; 1 transitional; achromia. She com- 
plained of considerable pain, appeared quite ill, and was irrational at times. The 
®P- gr. of the urine was 1.010; there was a trace of albumin and the urine was nega- 



854 : AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 

tive for sugar. Microscopic examination revealed a few leucocytes and also epithelial 
cells. 

Ten cubic centimeters of metaphen 1:1,000 were given intravenously. The 
temperature dropped to 100” the following day. Two days later the temperature 
reached 99°, then became nomal. The patient was discharged in good condition. 

The urine after the injection of metaphen was as follows: Sp. Gr. 1.009, no 
albumin. Microscopic examination was negative. The Wassermann was negative. 

Case 5. — 0. B., aged forty-seven, female, admitted to the hospital March 27, 1931. 
Cliief complaint on admission to the hospital — for the past three months, dysuria 
and pain in lower abdomen. Pelvic examination: cervix firm and pushed to the 
right, profuse wlute discliarge coming from the external os. The uterus seemed 
fixed and there was a hard mass about the size of an orange; it was felt anterior 
to the uterus which was tender on palpation. The diagnosis was fibroid uterus. 
Studies on admission: Wassermann negative, urine acid 1.021, few epithelial cells. 
The blood count was as follows: red blood cells 4,910,000; leucocytes 5,100; 
hemoglobin 80 per cent; polymorphonuclear cells 42 per cent; lymphocytes 40 per 
cent; eosinophils 2; and transitional 18. 

Operation, March 31, 1931, was vaginal hysterectomy and left salpingooopho- 
rectomy. The patient stood the operation well and seemed in good condition when 
returned from the operating room. That afternoon, the temperature suddenly rose 
to 105.4° F., pulse became very weak and rapid, the patient having chills and 
fever and temperature ranged between 103° and 105° F. The patient received 50 
per cent of glucose intravenously, and seemed improved, but the temperature still 
fluctuated as before. 

On April 12, 10 c.c. of metaphen 1:1,000 were given intravenously. The 
temperature now ranged between 98.8° and 100 A”. The patient was feeling well until 
the fifteenth, when she had another chill and the temperature went to 104°. Ten 
cubic centimeters of metaphen 1:1,000 were given again, intravenously. On April 
23, the patient received 10 c.c. of metaphen intravenously, although she felt much 
better and the temperature was coming- down. On April 25, 1931, the patient was 
given 375 c.c. of blood intravenously, mostly for the anemia. She had a slight 
reaction, after which the temperature came down to normal and continued so. The 
wound healed and the patient was discharged in good condition. 

Blood culture: Staphylococcus aureus. 

Case 6. — G. C., aged twenty-seven, white, female. Mlien first seen at patient’s 
home, chief complaint — chills, fever, pain in right loin and lower abdomen, nausea 
and vomiting, associated with dysuria. This patient gave birth to a living child 
spontaneously four months previously. The puerperium not complicated and the 
convalescence uneventful. The onset of present illness sudden, with the above 
symptoms. 

On examination, the patient’s temperature was found to be 104.4° F., pulse 
145, respiration 24. The white blood count 24,000; polymorphonuclear cells 90 
per cent. The urine showed many pus cells; if specimen was permitted to remain 
in liter jar, about one-half was pus. The temperature ranged for ten days between 
105° F. and 102° F. The patient had drenching sweat, and the prognosis did 
not appear to be good. Various urinary antiseptics and the usual treatment for 
pyelitis were tried -without any improvement. 

As a last resort, 10 c.c. of metaphen 1:1,000 were administered intravenously; 
at this time, the temperature was 104° F. There was no reaction following the 
injection. The following morning the temperature was found to be 101°. The 
next day 10 c.c. of metaphen 1:1,000 were again administered by the intravenous 
route. The temperature dropped to 100° F., then to normal, and continued so 



BERNSTINE : PITERPERAL SEPTICEMIA 


855 


without a rise. The patient was subsequently observed for several months; there 
was no recurrence and the patient is in good condition at the present time. 

When the patient was last observed, which was about one year following the 
illness, the following studies were made: X-ray of kidneys, kidney fimction test 
and urinalysis, and white blood studies including blood count. Nothing abnormal 
was observed. 

Case 7. — A. T., female, admitted to the hospital on April 11, 1931. She was 
delivered of a macerated fetus on April 8. On admission the patient complained of 
severe lower abdominal pain and was bleeding profusely. Temperature was 102° ; 
respiration 30; pulse 120; urine, acid, sp. gr. 1.020, trace of albumin, very many 
leucocytes. On examination, the fundus was felt at that time two inches above the 
symphysis pubis; very tender, and marked rigidity in left lower quadrant. The 
Wassermann was negative, the blood chemistry as follows: sugar 78; blood urea 
10; red blood cells 2,900,000; leucocytes 7,400; polymorphonuclear leucocytes 67 per 
cent; lymphocytes 25 per cent; eosinophils 6 per cent; transitional 2; and achromia. 

On April 16, 1931, 10 c.c. of metaphen 1:1,000 were given intravenously. On 
the twenty-third, 10 c.c. were again administered intravenously, the temperature 
ranging between 98° and 99.4°, and the patient improving. On May 11, 10 c.c. 
of metaphen were again given intravenously; temperature normal and patient 
feeling very well. Patient signed release on the twelfth, going home. Follow-up 
showed that this patient had no recurrence of symptoms and was feeling very well. 

Case 8. — E. W., female, admitted to the hospital March 31, 1931. Diagnosis: 
pregnancy at term, patient in labor, right occiput posterior; head rotated man- 
ually, forceps applied. Head delivered after median episiotomy. She was deliv- 
ered April 1, 1931. On April 4, it was noted that the patient had a thick dark 
red vaginal discharge with a slight odor. On April 5, 1931, the patient had chills, 
face flushed, seemed listless and drowsy, temperature 104°, pulse 120. The blood 
count on April 5, 1931, was as follows: red blood cells 4,420,000; leucocytes 15,200; 
hemoglobin 70 per cent; polymorphonuclear leucocytes 84 per cent; lymphocytes 
12 per cent; transitional 3. Patient complained on April 7 of abdominal dis- 
tress, the abdomen being somewhat distended. 

On April 13, 10 c.c. of metaphen 1:1,000 w'ere given intravenously; patient 
feeling somewhat better, general condition fair. On April 20, 1931, the tempera- 
ture somewhat elevated, patient seemed somewhat drowsy; slight abdominal pain. 
On April 21, 10 c.c. of metaphen w'ere given, and also on the twenty-third. The 
patient felt better and the temperature reached normal. General condition good; 
she seemed to be improving steadily. On May 3, 1931, no complaints, temperature 
normal, and on May 5, 1931, the patient was discharged in good condition. 

Case 9. — p. C., female, was operated upon several weeks previous to admission, 
for gall bladder disease, a cholecystectomy having been performed. She was ad- 
mitted on April 15, still complaining of severe pain in back and lower abdomen, 
associated with nausea and vomiting; also chills and fever. Patient was pregnant 
about five and one-half months, and had marked tenderness over costovertebral 
ungle. On admission, the blood count was as follows: red blood cells 2,160,000; 
leucocytes 7,500, polymorphonuclear leucocytes 88 per cent; lymphocytes 9 per 
cent; eosinophils 1 per cent; and transitional 2. The urine was straw color, acid 
ur reaction, sp. gr. 1.010. There was a cloud of albumin, and there were very 
many pus cells. The blood sugar rvas 102 and the blood urea 11. The patient 
iras admitted on a stretcher with a temperature of 104° P. 

She was given 150 c.c. of 50 per cent glucose, after which she vomited and 
complained of severe pain and having chills. She received her first injection of 



856 AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOG"^ 

metaphen 10 c.c. intravenously on May 7, 1931. The vomiting stopped, patient 
still nauseated, temperature 101°. On May 11, 1931, 10 c.c. of metaphen "were 
given again intravenously. Patient still complained as before. On May 13, 1931, 
patient was again given 10 c.c. of metaphen intravenously, the temperature- reach- 
ing normal on this date. On the fourteenth, 10 c.c. - were again given, patient 
felt very much better, and seemed more cheerful. Urine at this time was amber, 
acid in reaction, sp. gr. 1.022; there was a trace of albumin, few epithelial cells, 
and many leucocytes. On May 19, 1931, the patient was up in a wheel chair, 
temperature, pulse, and respiration were nonnal. On May 20, 1931, patient was 
discharged in good condition with normal temperature and without any complaints. 
Pollow-up showed no recurrences. 

Case 10. — ^B. S., female, aged twenty-one, admitted to the hospital Nov. 5, 1928; 
evidence of criminal abortion at tlie sixth week of pregnancy. Complaint on 
admission — marked abdominal distention and rigidity. Patient’s temperature was 
104° P. ; pulse 140; respiration 30; the blood count as follows: red blood cells 
5,200,000; leucocytes 22,700; hemoglobin SO per cent; polymorphonuclear leucocytes 
92 per cent; lymphocytes 7 per cent; transitional leucocytes 1. 

Ten cubic centimeters of metaphen 1:1,000 were given intravenously; tempera- 
ture down to 100.8°; pulse 120; respiration 25; blood count: leucocytes 19,950; 
polymorphonuclear cells 93 per cent; lymphocytes 7 per cent. Patient felt some- 
what better. On Nov. 7, 1928, 10 c.c. of metaphen were again given intravenously, 
temperature reaching normal, pulse 90; blood count now was: leucocytes 10,750; 
polymorphonuclear leucocytes 79 per cent; lymphocytes 21 per cent. Patient im- 
proved and was discharged in good condition on Nov. 17, 1928, the temperature 
being perfectly normal. 

In addition to the metaphen therapy, the patient also received digitalis and 
operative treatment. It will be interesting to note that this patient returned sev- 
eral months later to my office still pregnant and was subsequently delivered of a 
normal healthy child. 

Case 11. — G. S., female, admitted to the hospital April 6, 1931, and was deliv- 
ered that evening. Diagnosis was right occipitus posterior; manually rotated and 
forceps delivery. Patient was delivered without lacerations. The temperature 
continued practically normal until one week later, when it reached 103° P., pulse 
going to 102 and respiration to 25. On April 15, the temperature reached 105°. 
The lochia was verj^ foul. On examination, the fundus uteri was found to be mid- 
way between the sjunphysis pubis and the umbilicus. There was also tenderness 
on both sides of the uterus, more marked on the right. The heart and lungs were 
normal. Urine examination essentially negative. 

Ten cubic centimeters of metaphen were given intravenously; temperature 
dropped to 103° P. and finally to 100°, but the following day it again reached 
103° and finally 104°. Ten cubic centimeters of metaphen were again given intra- 
venously and the temperature gradually dropped, reaching 99° on the eighteenth 
and normal on the twenty-fourth. On the twenty-sixth of April, patient feeling 
well, no tenderness, veiy much improved. Patient was discharged on April 28 in 
good condition. 

DISCUSSION 

Case 1 represents a ease of renal calculus and B. coli coinninnis bac- 
teremia ; the patient ivas extremely ill, and various forms of medica- 
tion were tried, the patient being ill for fifteen days before metaphen 
was given intravenously ; after two injections, the temperature reached 



BERNSTINE ; PUERPERAL SEPTICEMIA 


857 


normal -witlioiit any reaction and remained normal, tlie patient recov- 
ering completely. 

Case 2 represents a case of Streptococcus liemolyticus septicemia, 
probably secondary to an infectious arthritis of the knee joint. Posi- 
tive blood cultures were obtained repeatedly from June 13 until June 
26, when the culture was reported negative and remained so until the 
patient’s discharge from the hospital. During this patient’s illness, 
he received six injections, 10 e.c. each, of metaphen 1 ;1,000 intra- 
venouslj'-,- there were no reactions or evidence of gastrointestinal or 
renal irritation. The patient made a good recovery except for an 
ankjdosed knee as a result of the infectious arthritis. 

Case 3 represents a case of Streptococcus liemolyticus septicemia 
following an incomplete abortion, complicated by splenic infarct. 
This patient- was extremely ill, her temperature reaching 105° P., and 
at times her pulse was so rapid that it was impossible to count it. She 
received tivo injections of metaphen 1 ;1,000, 10 e.c. ; the tempei’atnre 
became normal. The patient’s spleen was no longer palpable, and 
she began to gain weight when she was discharged from the hospital. 

Case 4 represents a case of eriminal abortion. The patient was ad- 
mitted to the hospital eight days after the induction. On admission, 
the temperature was 105° F., the pulse 135, the respiration 30, and the 
patient was delirious. Ten cubic centimeters of metaphen 1 :1,000 
were given intravenously and the temperature reached 100° P. the 
following day. Two days later, another injection of 10 c.c. of meta- 
phen was given, and five days after the first administration the patient 
left the hospital in good condition. 

Case 5 represents a case of Staphylococcus septicemia following 
supravaginal hysterectomy and left salpingo-oophorectomy. The pa- 
tient was extremely ill, the temperature reaching 105° F., accom- 
panied by dailj^ chills, then dropping to subnormal. The patient re- 
ceived three injections of metaphen 10 c.c., 1 :1,000 intravenousljL She 
was discharged six weeks following the operation in good condition 
with the wound healed and no complaints. 

Case 6. Acute pyelitis, the urine wms loaded with pus, the tempera- 
ture reaching 105° P., white cell count 24,000 with 90 per cent poly- 
moiifiionuclear cells. The pulse and respiration were correspondingly 
accelerated. Various forms of therapy were tried; finalh% an intra- 
''’enous injection of 10 c.c. of metaphen 1:1,000 was given; the tem- 
perature dropped promptly from 105° P. to 101° F. without reactions. 
Two daj's later, 10 c.c. of metaphen was again administered by the 
uitravenous route, the temperature reaching normal and remaining 
so ; the patient made a complete reeoverjL 



858 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


SUMMARY 

Tlie following factors concerning septicemia and its treatment appear 
to deserve especial empliasis : 

1. In tlie usual conception of septicemia, attention is focused on tlie 
organism in the circulating fluids of the body to the exclusion of all 
other factors, while in reality, septicemia is a recognized clinical en- 
tity, of which the presence of invading organisms at some time in the 
blood stream is only one feature. 

2. It is well to bear in mind the fact that septicemia is bj’" no means 
of rare occurrence, as the statistics quoted at the beginning of this 
article testify, and that the problem, therefore, requires the serious 
consideration of the medical profession. 

3. It is important that cases of septicemia should be studied both 
clinically and in cooperation with the laboratorjL 

4. Septic cases demand early diagnosis, isolation, and proper treat- 
ment. 

5. Hospitals should have special sections for septic cases, in which 
ideal conditions and adequate treatment may be provided. 

6. Research on the prophylaxis, causes, and treatment of septicemia 
by the medical schools, with cooperation of various departments, is 
necessary for advances in this field. 

7. It is my opinion that at the present time there is no bactericidal 
agent which can be safely introduced into the blood stream in quan- 
tities sufficient to sterilize it eompletelj’-. Howevei’, we have found 
that metaphen 1 :1,000 when introduced into the blood stream exer- 
cised a marked bacteriostatic effect on the invading organisms ; if the 
resistance of the individual could be reinforced at the same time, our 
results would be most gratifjdng. 

CONCLUSIONS 

In our study stretching over a period of several years, many cases 
of various blood stream infections have been studied and closely ob- 
served, metaphen 1:1,000 having been used intravenously. Our re- 
sults in the majority of cases have been remarkably gratifying, and 
in no cases have we found evidence of toxic effect or untoward reac- 
tions due to the treatment with this drug. On the basis of these 
observations, we have come to the conclusion that metaphen when 
introduced into the blood stream of individuals suffering from sep- 
ticemia, acts as a bacteriostatic rather than a bacteidcidal substance. 
We believe that this property alone is responsible for the conspicuous 
absence of reactions; at the same time, the disease is treated along 
natural lines, since the individual’s own resistance is permitted to 
play the prominent part which it should play in combating all in- 
fections. • . 



BERNSTINE : PUERPERAL SEPTICEMIA 


859 


REFERENCES 

(1) Bland, P. B.: M. J. & Eecord 129: 135, 1929. (2) Kilduffe, B. A.: J. Med. 
Soc. New Jersey 25: 13, 1928. (3) Trout, E. H.: Surg. Gynec. Obst. 42: 633, 

1926. (4) Baisiss, G. TV., and Severac, M.: J. Lab. & Clin. Med. 9: 71, 1923. 

(5) Baisiss, G. W., Severac, M., and Moetsch, J. C.: J. Pharmacol. & Exper. 

Therap. 26: 447, 1926. (6) Baisiss, G. W., and Severac, M.: J. Infect. Dis. 40: 

447, 1927. (7) BirMaug, K. B.: J. A. M. A. 95: 917, 1930. (8) Bernstine, 
J. B.; Am. J. Obst. & Gynec. 18: 220, 1929. (9) Spotts, S. D.: J. Chemotherapy 
4: 48, 1927. (10) Fisher, B.: Qin. Med. & Surg. 34: 857, 1927. (11) EuBois, 

Leo G.: Clin. Med. & Surg. 35: 331, 1928. (12) Bledsoe, B. E. B.: J. Chemo- 
therapy 6: 37, 1928. (13) Keeler, E. B.: M. Clin. North America 16: No. 2, 

1931. (14) Eirschf elder, A. D., and Wright, E. N.: J. Pharmacol. & Exper. 

Therap. 39: 13, 1930. (15) Levinson, A.,' and Perlstein, M. A.: Arch. Path. 

12: 729, 1931. (16) Tileston, W.: Sepsis, Cecil’s Textbook of Medicine, 1927, 

W. B. Saunders Co., p. 69. (17) Eerrick, TF. W.: Nelson Loose-Leaf Med. 1: 
106; J. A. M. A. 71: 612, 1918; Cecil’s Textbook of Medicine, 1927, W. B. 
Saunders Co., p. 114. (18) Beclcanan, E.: Treatment in General Practice, 1930, 

p. 148. 

2007 Pine Street. , 


REPORT OF A CASE OF A^ATIO PLACE NTAE FOLLOWED 
BY SL OUGH ING OF T HE UTE RUS^- 
W. A. Coventry, M.D., and Russell J. Moe, M.D., Duluth, Minn. 

(From the Duluth Clinic) 

ES. S. F., thirty years of age, para i. Seen on March 12, 1932 at which time 
* she gave the following history: 

She had had one pre%ious pregnancy accompanied by premature birth with death 
of the fetus, cause unknown. The last menstrual period was Sept. 29, 1931. 
Apparently she was going through a normal pregnancy, having been under the care 
of a physician who stated that at no time was there any evidence of toxemia. On 
March 8, 1932 she was markedly shocked and frightened on the occasion of an 
explosion of a furnace in her home. At the time of the explosion she suddenly 
jumped out of bed, landing on her feet, but felt that she had jarred her body 
considerabl}'. At that time she had some pelvic and abdominal pain ■which after a 
few hours disappeared and she says that she felt fairly well for the next two days. 
She again consulted her physician because of the fact that she felt weak, faint, and 
Ijecame very pale. Her condition was alarming enough to have her removed to a 
small private hospital where during the next two days she suffered severe abdominal 
cramps which were constant in character and she remained extremely pale and weak. 
1 aginal examinations were made, but no therapy except bed rest and relief of pain. 
At this time she came under our observation. 

The patient looked extremely ill, the conjunctiva and lips were almost a waxy 
''lute. Temperature 99°. Hemoglobin 35 per cent with 1,500,000 red blood cells. 

rinalysis was negative. Blood pressure 110/60. The abdomen was markedly' dis- 
^nded with the skin shiny. The uterus appeared to fill the entire abdominal ca'vity. 

>c abdomen -n-as so hard and firm and so extremely tender that it was impossible 
to outline the uterus. The heart tones could not be heard and there was no placental 
-oufllo. There was no bleeding from the vagina. 

anti Fourth Annual Meeting of the Central Association of Obstetricians 

'-’Jnecoiogists, Memphis, Tenn., September 15-17, 1932. 



860 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


A diagnosis of ablatio placentae was made and the patient was immediately pre- 
pared for cesarean section, which was performed nnder spinal anesthesia. Anticipat- 
ing the necessity for transfusion, donors were obtained. Upon opening the abdo- 
men the uterus was found to be very markedly distended, very thin, verj' tense, and 
dark blue in color. The muscle fibers of the uterus seemed to be “teased” apart — 
necrobiosis. A large amount of blood and clots was found between the membranes 
and the inner wall of the uterus. The fluid was aspirated, the membranes opened 
and the dead fetus delivered. Also the placenta delivered without any incident. 
Pituitrin was immediately given, but the musculature of the uterus was so flabby 
and had lost its tone to such a degree that the pituitrin had no effect upon con- 
traction. The wound was closed in the usual manner and intravenous glucose 
and saline resorted to at once. Hysterectomy was not performed because the 
patient was too ill, and we thought it poor judgment to subject the patient to 
further surgery. 

During the first week postoperatively the patient’s convalescence was exceedingly 
stormy. There was a great deal of ileus with accompanying distention. At no 
time was there any sign of obstruction. After a week the bowels began to move 
and the distention disappeared. Then we were able to outline the uterus above the 
level of the navel. No involution had taken place, in fact the uterus was larger 
than one would expect at this time postpartum. It was our opinion that the 
patient was bleeding into her own uterus. During this time five blood transfusions 
were given with good response. 

On the tenth day postoperatively the sutures were removed and the wound was 
probed with the result that there was a discharge of considerable amount of gas 
through the probed wound. Our first impression was that there might have been a 
perforation of the intestine. The release of this gas gave the patient a great deal 
of relief. Accompanying the gas there was considerable old, blood-stained fluid. 
The edges of the wound finally separated and we were able for several days to re- 
move daily nearly a quart of blood-stained fluid. Profuse drainage continued for 
ten days. At no time was there any evidence of fecal material. Slough now 
appeared in the wound and at fii'St we thought this was due to necrosis of the 
abdominal fat or the omentum, but on further examination it was found that the 
uterus itself was sloughing out of the abdominal wound. When more slough ap- 
peared and more was cut away, it became apparent that the omentum had- formed 
a wall above the uterus, walling off the small intestine and that the uterus itself 
was sloughing through the abdominal wound. The patient was showing no -evidence 
of peritonitis; the bowels were moving regularly; and the appetite was good. 

Phlebitis appeared on the twenty-second day accompanied by the usual rise in 
temperature and pulse. This phlebitis was in both limbs. The condition was given 
appropriate treatment. Eventually the wound healed by secondary intention and 
at the end of four months the patient was discharged from treatment. However, 
before discharge attempts were made to inject the uterus with lipiodol, and we 
found that the uterus except for the cervix had entirely sloughed out through the 
abdominal wound. 

In our review of the literature we have been unable to find any case report of 
sloughing of the uterus through the abdominal wound following this condition, and 
we attribute the cause of this entirely to the' fact of the marked necrobiosis of 
the uterus, cutting off the blood supply to the muscle itself. 



CONGENITAL DEFECTS 0F-T-HELSCALP 
Studies in the Pathology of Development, III 
N. William Ingalls, M.D., CLE^^ELAND, Ohio 

(From the Anatomical Laboratory, Western Beserve University) 


M inor aberrations and disturbances in what may be called the 
typical or nonnal characters of the slun, particularly as regards 
pigment, hair, glands and vascular supply, are so common that they 
constitute the rule rather than the exception. This is not surprising 
in view of the relatively large expanse of cutaneous surface and the 
peculiar qualities and capacities inherent here; a sensitive, adaptive and 
at the same time a protective body covering of remarkable efficiency. 
One can hardly expect anytliing approaching uniformity, much less per- 
fection, over an area of from 18 to 20,000 sq. cm., some 20 sq. ft.; 
especially in a structure, like the skin, where slighter or even more 
marked deviations from the normal are, as a rule, of little or no prac- 
tical significance. In marked contrast with this extreme, even common- 
place varialiility of the skin for minor details, is the relatively rare 
occurrence of actual defects, however small. 

The extreme rarity of cutaneous defects, in comparison with the 
possibilities for other types of maldevelopment here, can only mean 
that the natural, inherent factors at work in covering the body with 
some kind of an epithelial layer, are far more ancient, more deep-seated 
and fundamental, more tenacious and stubborn, than those influences 
which prescribe the finer details of that covering layer once it has been 
established. Or, in other words, relatively feeble or late-acting develop- 
mental, or other factors may suffice to bring about variations in sldn 
details; but in the case of frank defects, absence of skin, one must 
invoke some far more powerful and more incisive genetic influences, or 
take refuge, for etiologic purposes, in actual trauma, physical violence 
or some other external form of tissue destruction. 

Not onlj'’ are cutaneous defects very infrequent, but they are of par- 
ticular interest because they are most commonly located on the scalp and 
moreover, as a rule, on the A’-ertex, in or near the median line. It is 
ivith this manifest predilection of a rare cutaneous condition for a 
definite part of the bodj’’ that we are primarily eoncenied at this time. 

As late as 1910 Kehrer noted only 32 cases of scalp defects in the 
hteraluro, adding one of his omi. In 1924 Heidler could find but 42 


cases and in 1930 Terruhn cites 76 cases of scalp defects and 29 eases 
f>f skin defects elsewhere on the body. Doubtless, as Heidler suggests, 
there may be many cases which have not found their way into tlie 
ilerature since the slighter defects may be quite inconspicuous and of 


SCI 


862 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


little practical importance. We have made no attempt whatever to 
exiiaust the literature on scalp defects, but such references as we shall 
malie are based on some 60 cases. As the most important literary 
sources we may note Kehrer 1910, Bettmann 1912, Walz 1924, Lund- 
wall 1927, Terruhn 1930 and Greig 1931, few other specific citations 
will be made. 

Briefly, the more important features of these 60 cases, more or less 
satisfactory as to the data recorded, may be noted as follows; 

In more than half the eases, the defects are in the mid-line, often 
noted as “exactly” in this position, and in over 80 per cent they are 
in or near this location. They are most commonly found near the vertex, 
“am Scheitel”; as a rule somewhere along the sagittal suture or in 
the region of the fontanelles, more frequently over or near the posterior 
than the anterior fontanelle. Exeeptionallj’^ they may occur more 
laterally, over the parietal, in the neighborhood of the ear, or on the 
forehead. In some 70 per cent of cases the defect is single and in 
about 20 per cent double; in a little over 8 per cent there were 3 defects, 
while in one case, 1+ per cent, 4 were noted. In this respect cutaneous 
scalp defects differ, and significantly, we think, from skin defects else- 
where which are almost, if not invariably multiple. Where more than 
one scalp defect is present, there is a well-marked tendency, more than 
a third of cases, toward a symmetrical arrangement and a similar tend- 
ency is often noted in defects on the trunlc or limbs. 

As regards the gross features of scalp defects there is considerable 
variation, due, no doubt, to the extent or degree of the original damage 
and tlie vaiying amount or success in the subsequent healing. The 
only common character in all of these cases would appear to be the 
absence of hair, and it may very well be that certain of those cases 
described as congenital alopecia, not to mention other conditions, reallj^ 
belong in this category and share in the same etiologic background. 
As a rule the defects are not large, from 1 to 2 cm. in diameter, but 
they may be much smaller, less frequently larger, and only rarely of 
the huge dimensions occasionally noted, up to 50 sq. cm. Not infre- 
quently, particularly in regards to the smaller defects, the form may 
be quite regular with sharp margins, the whole often being described 
as pimched out in appearance. Some defects appear fi’esh, as if newlj'^ 
made, others show more or less complete, often irregular, eicitrization, 
while in many cases there is a well-defined, narrow, hairless or otherwise 
altered margin, separating the defect from the nonnal scalp. The sur- 
face may be smooth and dry, or more raw and moist, granulating, hemor- 
rhagic, later even suppurating. In the majority of cases the defect in- 
volves only the epidermis and the subjacent cutis to a varying extent, 
but it may extend to the galea, or even beyond this to the pericranium 
and dura. It is particularly in these deep defects that the underljdng 
or neighboring bone is defective, thin and parcliment-like, or tlie sutures 



IN6AX.LS: CONGENITAL, DEFECTS OF THE SCALP 


863 


and fontanelles maj" be unusually wide. In Alilf eld’s case, quoted from 
Kelirer, No. 22, there was a lock of hair of unusual length growing from 
the margin of the defect, a very suggestive finding. 

In five eases, a little over 8 per cent, there were skin defects else- 
where on the body. Much more frequently, however, too often probably 
to be a mere coincidence, scalp defects are associated with some of the 
commoner malformations of other parts but in only a third of our 
cases is it noted specifically whether, except for the scalp condition, the 
child was normal or not. Most frequent among these associated 
anomalies are those affecting some part of the head; hydrocephalus 
meningocele, eheilo- and palatoschisis, eoloboma, microphthalmos, in 
the limbs a variety of conditions have been observed. 

Of special interest is the condition of the fetal membranes in these 
cases, because of the reputed role of the amnion in bringing about 
these, as well as other defective states. Unfortunately in most instances, 
particularly in the older records, there is no good evidence on this 
point, in the present series there is usable information in only 16 eases. 
In 11 of these the membranes are noted as normal, once there was 
hydramnios, twice oligohydramnios ; but only three times, once in asso- 
ciation with oligohydramnios, are amniotic bands or adhesions men- 
tioned. 

Among the cases where the sex is given females are in the majority, 
and this preponderance is still more accentuated in those cases of pre- 
maturity and early death. In a little over half the cases, where data 
are given, the affected child was the first, and some emphasis has been 
laid on the greater tendency in primiparas to oligoliydramnios, lesser 
distensibility of the uterus and a more probable lack of room for the 
developing fetus. Anomalies of presentation also seem to be particularly 
common. 

Not infrequently the family history provides information of great 
importance in the consideration of etiologic factors. One case was that 
of a fourth child, premature at seven months; the first child had died 
at seven weelcs, and the third Avas an abortion at three montlis. In 
another the scalp defects occurred in a fifth child, the first three being 
premature, the fourth Avas a rachisehisis. Sitzenfrey’s case Avas also a 
fifth pregnancy; the first child died at four montlis, the second and 
third Avere both hydrocephalic, necessitating peifforation, the fourth 
living at one and one-half years, shoAved a large head and open anterior 
fontanelle, Avhile in the fifth there Avas oligohydramnios and a hydro- 
meningocele at the lesser fontanelle. This case is exceptional, if not 
unique, in that the sldn defects A\-ere located on the meningocele. Even 
more suggestive are those cases AAdiere similar or possiblj* related 
anomalies occur in other membei*s of the same family. As long ago as 
1826, Campbell (Greig, 1931) reported an ulcer in the region of the 
posterior fontanelle in tAvo children of the same mother; the first died 



864 AMERICAN Journal of obstetrics ano gynecology 

of hemorrhage, the second at eight months from hydrocephalns. Burger’s 
ease is very similar, two children showing similar defects, the first 
dying within a few days. In Greig’s second case, besides the scalp 
defects, there were present complete harelip and cleft palate and 
polydactylism ; the father had an incomplete harelip. Graff, in report- 
ing what he terms aplasia cntis congenita, notes a combination of some 
of the conditions noted above. The scalp defect occurred in a fourth 
premature child, the preceding three pregnancies had terminated early, 
at seven and eight months, and in all three there was early death of the 
child. In this case the father presented, in exactly the same place, a 
small circular tonsure, and in the case of both father and child the mid- 
wife had been blamed. 

As regards the etiologie factors at work in the production of skin 
defects both on the scalp and elsewhere, there is still some divergence 
of opinion. The older, amniotie origin of these, as well as many other 
types of malformation, was accepted by ICehrer, who first collected a 
large number of these eases, and who considered amniotie anomalies 
as the only possible explanation. As a result of infiammatory changes, 
of unlmown origin, an amniitis, adhesions are formed between the 
amnion and embryo, either the solid bands of Ahlfeld or the hollow 
forms of Simonart. These in turn, by their traction of the developing 
skin, due in part to fetal movements, etc., may tear out pieces of 
integument, although later these offending bands may disintegrate and 
disappear entirely. This point of view is all the more remarkable 
since in the 33 cases noted by Kehrer the membranes are given as nor- 
mal in a number of instances, but not once is there good evidence of 
the presence of adhesions. Indeed the condition of the membranes, 
amnion, is held to be of no diagnostic consequence. 

Following Kehrer, and apparently inspired by him, Oing, 1929 but 
more esp'ecially Terruhn, hastened to the defense of the fading am- 
niogenic theory. Neither of Oing’s cases, however, showed amniotie 
adhesions, but following a diligent hour and a half search Terruhn was 
rewarded, in one of his two cases, with a solid amniotie band, 8 cm. 
in length, with fresh fiesh-colored fragments and clotted blood on the 
free end. We are appraised, in italics, and there are many other italics 
in his article, that this is the first time that such conditions had ever 
been found. 

Terrulin’s long and imposing array of cases is anything but con- 
vincing however, and we cannot see that either his conclusions or his 
statistics are adequately supported hy the evidence presented. Jluch 
has been written about a hypothetical amniitis and a close fitting am- 
nion, both of which would seem to conspire to disturb proper gro-wth 
and development. But the largelj’- imaginary existence of these condi- 
tions, the aclmowledged rarity of actual adliesions, the very frequent 
sjunmetrj’- and peculiar characteristics and localization of the sldri de- 



INGALLS: CONGENITAL DEFECTS OF THE SCALP 


865 


fects in question, together with the obvious evidence of the participation 
of endogenous, hereditary factors in manj’’ eases, gradually lead to the 
conclusion that, as Heidler remarks, the amniogenic theory had been 
"gewaltig iiberschatzt. ” More and moi'e the almost total lack of evi- 
dence pointing to 'primary amniotic influences became apparent, and 
here, as in most other malformations, the paramount importance of in- 
ternal, inhei’ent, often hereditarj' factors, rather than external physical 
conditions, was recognized as the fotis et origo mali. As noted above 
there are a significant number of cases in which the family histoiy 
indicates, in one way or another, the influence of endogenous factors, 
and statistically these eases far outweigh those showing possibly causa- 
tive amniotic conditions. Not only in skin defects, so called, but in those 
more serious eases of what are Imoum as intrauterine amiiutations, there 
is likewise evidence of internal, possibly also hereditary factors (Streeter, 
1930). 

Many, if not all congenital scalp defects, excepting naturally those 
of obviously traumatic origin, can be explained, we believe, on the basis 
of inherent developmental factors which impress upon the mid-line of 
the head a degree of sensitivity or vulnerability equalled perhaps no- 
where else in the body. Iir a previous paper (1932, 1) we have dis- 
cussed the character and soui’ce of normal developmental factors and 
their relation to maldevelopment, particularly in the dorsal region of 
the human body. Subsequently (1932, 2) we enlarged upon this theme, 
more from the standpoint of pathology and further illustrated our 
position by preseirting a number of cases of early pathologic processes 
in human embryos. Briefly put, one may say that the dorsal mid-line 
of the vertebrate body, and more especially the human body, is char- 
acterized by a veiy definite instability and variability, due to the in- 
herent capacities and potentialities, the peculiar and complex genetic 
constitution of the cells and tissues involved and of the relatively mas- 
sive and extremely important rearrangements which must be eflected 
here. The direct result of these unstable, even vulnerable conditions is 
seen, on the one hand, in the extreme frequency of major mid-line de- 
fects, anencephaly, rachischisis, etc., and on the other in those com- 
paratively rare head or scalp defects which we are considering at pres- 
ent. These, as well as other anomalies, belong in one and the same 
category as suggested by Walz. They stand at either end of a long 
end complicated series; ranging all the way from gross, extensive de- 
fects, extending from the skin through the cavity of the nervous system, 
dm\^^ to cutaneous anomalies so slight that they may be overlooked en- 
tirely. It is paradoxical perhaps, that the former should be so common, 
while many of the latter, scalp defects, arc so rare. Not only is the mid- 
fine particularly unstable and vulnerable during development, but there 
is often a well-marked predilection for the embryonic head, correspond- 
with the favorite site of scalp anomalies. We have noted a number 



866 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


of instances of this in onr second article (1932) and abundant evi- 
dence in the same direction is provided by the extensive -works of Mall, 
1908 and Mall and Meyer, 1921. Curiously enough, those gross mid- 
line defects -which are so frequent at term, are not commonly seen dur- 
ing the early -weeks of gestation, -while the smaller superficial anomalies, 
from -vs^hieh -we derive the rare scalp defects, are by no means unusual 
during this period. One must either conclude that many of the in- 
cipient stages undergo complete restoration, or their remains are al- 
ways overlooked, or else the conditions in these cases, whether internal 
or external, are more serious or more lethal than the apparent extent 
or severity of the damage would lead one to suppose. In the former, 
the term cases, the dei*angements may he more in evidence in the fetus 
than in the adnexa, while in the latter the embryo escapes to a large 
extent, hut its membranes and its nutritional sources are so altered or 
compromised that eaiij'- death and abortion are the result. 

In these early cutaneous, or superficial alterations on the embryonic 
head, we have the first signs of those abnormal or even pathologic 
processes which may persist until term when they appear as scalp de- 
fects of varying extent and severity. In their initial stages, as later, 
they may exliibit a variety of characters. The area involved may be 
larger or smaller, the effects may be confined apparently to the cover- 
ing epithelium or the underlying connective tissue, as well as deeper 
structui’es maj’’ share in the general process. Blebs or bullae may be 
formed just beneath the epithelium, or there may be accumulations of 
fluid at a deeper level. The epithelium may be, to all appearances, 
normal or it may be absent or tom away and frequently there are ir- 
regular and erratic epidermal thickenings bounding the defect. Both the 
superficial and deeper layers may be modified in a variety of ways, 
-without its being possible to determine how severe the damage may be, 
how long the process may have been active or what the probable out- 
come would have been. In some cases it would seem as if complete 
restitution might have been possible, but it must be remembered that 
one is not dealing here with some hypothetical damage to healthy, nor- 
mal tissues, but rather -with structures which are inherently abnormal 
or tainted, and their unusual and in part unnatural bent to faulty 
development may very well mean also a diminished, ineffectual or other- 
wise perverted capacity to restore normal conditions. Judging from 
the final results, as seen at the end of pregnancy, this healing process 
varys greatly; but rarely if ever is normal sMn produced, and very 
often there seems to have been only veiy feeble attempts at restoration. 
All of this would indicate that the damage done is very deep seated, 
affecting adversely the proper potentialities of the cells concerned, rather 
than any simple trauma to ordinarj’- tissue. As regards this capacity 
for healing, there seems to be a well-marked difference in the behavior 
of these typical scalp defects and those encountered elsewhere on the 



INGALLS: CONGENITAL DEFECTS OP THE SCALP 


867 


body. Although the latter are as a rule far more extensive, often 
multiple as well, they are much more often completely cicatrized, or 
apparently of less recent origin, and they do not present the sharp 
punched out, fresh appearance of the typical scalp lesion. These dif- 
ferences are, we think, the expression of the greater initial damage, 
the more profound alteration in the inherent capacities of the cells in 
the mid-line, more particularly on the scalp, and such disturbances prob- 
ably date from an earlier embryonic stage and are therefore more 
effectual in disrupting or retarding development. Although many of 
these cases show little attempt at intrauterine healing, as a rule there is 



Pis. 1. — Embryo No. 611, 23 mm. Ions. Small thin walled bleb over cerebellum. 
Farther forward in the mid-line there is a second deeper accumulation of fluid, not 
visible here. 


relatively rapid healing after birth. It would seem as if continued 
immersion in amniotic fluid, which may not always be normal, was un- 
favorable and more so in the ease of scalp conditions than in those 
located on other parts, or farther from the mid-line. In Hoffel’s ease, 
cited by Lonne, 1921, there ivas a large defect on the back from which 
hand-like extensions encircled the trunk. Of these more lateral bands, 
one was healed at birth and the other in two weeks, but the dorsal defect 
was not covered over for more than two months. 

In none of our embtyonic eases are there any amniotic adliesions 
or any indications that they were likely to form. It is altogether pos- 



868 


AMERICAN JOURNAL OP OBSTETRICS ANt) GYNECOLOGY 


sible, of course, that connections might have been established later, over 
some of the raw spots and the connecting material might be embryonic 
instead of amniotic but in any ease the primary trouble appears in the 
embryo rather than in the membranes. AVe have no inclination to denj'^ 
the possibility that skin defects and adhesions may coexist, or that the 
latter may not even exert some influence upon the former but here, as 
elsewhere, their relation to the disturbed development is secondary and 
not primary. They are accidental features and not causal factors. 



Pig. -2. 

Fig. 2. — No. 597 B, 32.5 mtn. smaller twin, 
maiformed. 



Fig. 3. 


Large bulia over verte.v hands and cord 


Fig. 3 . — No 665, about 15 mm. Extensive symmetrical defect over anterior end of 
head, epithelium lacking. Face and head deformed, posterior end of body damaged. 


But aside from the sldn conditions exliibited by our series of embryos, 
there is additional evidence of a common etiologic background for both 
the early and late eases in the similarity of what we may call the 
family history, hereditaiy and external factors. Most of our embiyonic 
eases are from the second month, when the bulk of abortions occur, the 
menstrual history varies greatly, often these had been earlier abortions, 
the chorion is frequently abnormal often the site of cystic changes, 
hydramnios is not infrequent while in many cases there are accom- 



INGALLS : CONGENITAL DEFECTS OF THE SCALP 


869 


panying malformations in other parts of the body or the embryo may 
present a variety of pathologic rather than strictly teratologic conditions. 
For the later stages, from the literature, we have already noted the 
frequent miscarriages, prematurities, high fetal mortality and morbidity , 
and the presence of associated anomalies. 

A more extended account of these embi-yonie conditions will be found 
in our earlier paper, and we shall call attention here only to a few 
cases. 


Fig. 1 represents a 23 mm. embryo. No. 611, obtained from a hysterectomy for 
pelvic deformity, at ten weeks. In the mid-line over the cerebellum is a minute, 
thin walled bleb, and there are a few small scattered ecchymoses on the head and 
trunk. In the region of the bleb, only the epidermis is elevated, but farther for- 
ward, also in the midline there is a larger and deeper accumulation of fluid, not 
visible in the photograph. 

No. 597 B, Fig. 2, is considerably older, 32.5 mm., the smaller of twins and the 
second abortion out of three pregnancies. Just behind the vertex is a very con- 
spicuous, symmetrical bleb, 7 mm. in anteroposterior extent, the deeper structures 
are apparently not involved. The hands are malformed and the cord is badly 
kinked and twisted. Although in both of these cases the surface layer is stiU 
intact, it would have required but little to tear this thin distended membrane, as 
has happened in some of our cases, so producing an actual raw defect. The 
larger companion of No. 597 B is apparently normal in every way, and, if preg- 
nancy had continued, the smaller one might have appeared at term as a fetus 
papyraceus. We mention this because in a surprisingly large number of these 
eases showing cutaneous defects on trunk or limbs a fetus papyraceus was pres- 
.ent (Lundwall), in Biider’s case there was also an extensive scalp lesion. 

An actual loss of superficial epithelium is seen in No. 665, Fig. 3. The embryo 
is only 15 mm. in length and has suffered considerable postmortem damage. The 
defective area covers most of the anterior end of the head, it is remarkably 
symmetrical, of a brownish color and the bordering epithelium is irregularly 
thickened. 


Embryo No. 167, Fig. 4, is of particular interest since it shows multiple 
.anomalies on the head, all in or near the mid-line. On the back of the head there 
is a veiy striking, transversely disposed, symmetrical discolored area (of. Ingalls, 
2, 1932, Plate III, Fig. 10), in advance of this is a smaller spot and still farther 
forward high up on the forehead, Pig.;4, are, two symmetrically placed dark spots, 
even more conspicuous than the posterior ■■ one. ' T he eni thelium is for the most 
part intact, but there are evidences of its giving -vya^.) , Cutaneous defects have 
been noted in the frontal region in combination with'' similar conditions farther 
back, as in this instance. ' b-. 


In No. 442, Fig. 5, there is a very conspicuous, dark, sharply defined frontal 
band in much the same location as in the preceding case. This specimen was from 
a tubal pregnancy, following an earlier abortion; there w'as also an extensive 
defect in the sacral region behind. The covering epithelium seems to be intact, 
but there is some thickening along the margins of the area. j ^ 

In concluding we would note briefly the conditions present in No. 536, Fig. ''G.' 
There had been four previous miscarriages and one birth at eight months before 
this specimen was aborted. Bad tonsils and infected teeth are noted in the Iiis- 
tory as well as the possibility of syphilis. Some writers have thought that infec- 
tions in the-mother might predispose to- amniotic anomalies and adhesions and 






TNGALLS; CONGENITAL DEFECTS OP THE SCALP 


871 


sypliilis lias often been consideied among tbe etiologic factors involved in scalp 
defects. The most conspieuons changes here are seen in the mid-line of the back 
low dowm and higher up in the region of the shoulders, and in both places there 
is a very obvious symmeti’y, a condition very frequently encountered in skin 
defects. In this case the skin is thickened, denser, and more scaly than usual 
and the subcutaneous tissue seems more fibrous than in normal embryos, as if it 
might represent an early stage of the extensive fibrous cicatrices seen at birth, 
sometimes described as keloid in appearance. In this particular embryo, as well 
as in others, we have encountered a number of bizarre histologic findings which 
would seem, in some cases at least, to represent a distinctly pathologic process 
engrafted upon teratologic conditions. 

The interest and importance which attach to these congenital cutane- 
ous defects, more especially those of the scalp, is evidenced by the in- 
creasing number of cases which have found their way into the recent 
literature, chiefly in Germ.an obstetric and gynecologic journals. 

These scalp conditions, though relatively infrequent, have a special 
claim upon the attention of the obstetrician, since it is he, ordinarily, 
who would first become aware of their existence. Upon him would 
devolve the responsibilitj’’ for appi’opriate treatment, and it would also 
doubtless fall to his lot to offer some more or less satisfactory explana- 
tion. We think that Heidler is quite right in believing that scalp de- 
fects are more common than is generally supposed, and that only the 
more striking or more serious eases have been placed on record. That, 
as a rule, only the major and more serious defects are to be found in the 
literature may be infex’red from the mortality recorded. For the 60 
odd cases which we have considered, the mortality, including stillborns, 
was about 20 per cent, with most of the deaths more or less directly 
referable to the lesions present on the scalp. 

The fact that the majority of these cases go to term, naturally those 
which escape embryonic death or those in which the defect appears 
relatively late, and that these cases then show a sudden and significant 
increase in mortality, at or shortly after birth, would indicate that, 
from a practical standpoint, they may be looked upon as birth injuries. 
They are birth injuries, and also antenatal injuries or insults, of a 
peculiar character however, in that one may recognize predisposing as 
well as exciting causes. 

The predisposing influences are ingrained in the embrjmnic constitu- 
tion, they are essentially genetic, natural characters and they may there- 
foie assume an hei editary aspect. The exciting, or aggravating and 
complicating factors are of greater practical importance since they are 
amenable, in some measure, to treatment and control. They are to be 
found in the environment of the embryo and fetus, in the more or less 
abnormal and unfavorable condition presented by the maternal organ- 



872 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


ism, as witnessed by tlie uterine or menstrual disturbances, the number 
of abortions, often repeated, and the frequency and extent of abnormal 
changes in the membrane. 

Up to the time of birth these scalp conditions seem to be of only minor 
significance, but folloudng labor it is a very different story. There is 
little if any evidence, antepartum, of bleeding and still less of infection. 
After birth there is frequent and abundant evidence that the primary 
lesion has been more or less radically altered, and that for the worse. 
Hemorrhage is common, and the defect is often described as a fresh 
wound, which maj’’ even be infected. Indeed it is the apparent newness 
of the condition, and the obvious evidence of actual recent trauma which 
have more than once excited suspicion as to the possible role played 
by the medical attendant or midwife. The fact that these defects show 
onlj’’ feeble or imperfect attempts at intrauterine healing renders them 
all the more liable to damage and complication during or subsequent to 
labor. There can he no doubt that many of the abnormal conditions 
which we have encountered in early embryos, where the developmental 
disturbance has been very slight and where the skin or epidennis is still 
intact, would liave suffered very severely during labor, if tliese same 
conditions had been present at that time. This applies especially to the 
slighter, more superficial defects, bullae, etc., which could hardly have 
escaped rupture or more extensive laceration. Except for predisposing 
factors these would be typical birth injuries, there would have been 
actual damage and destruction of tissue; postpartum and antepartum 
conditions would have been quite different. 

The peculiar cliaraeter and significance of scalp defects are seen by 
contrasting them with cutaneous defects elsewhere. Although relatively 
infrequent, either alone or in association Avith scalp lesions, sldn defects 
on the body or limbs are usually multiple and often very extensive. 
In spite of this, however, they are of much less practical importance 
and they appear to suffer little or not at all during labor. Although 
they may be very large, they are superficial rather than deep, they heal 
much more readily than scalp defects, often before birth, and they do 
not shoAv the secondary complications of hemorrhage or infection and the 
consequent effect upon mortality; their significance is largely cosmetic. 

Scalj) defects belong in another categor}’, they have quite a different 
etiologic background, while the quality and integrity of the tissues have 
been much more profoundl.Y altered. Their important topographic rela- 
tions, the relative ease of injury and the feeble reparative capacities 
with which they seem to be endowed, all conspire to create conditions, 
the gi’avity of Avhich is often still further increased by the trials incident 
to or folloAving labor. 



RANDALL : HYSO'EKOSTOMATOMY 


873 


REFERENCES 

Bettmann: Die MissbiWungen der Haut. Schwalbe’s Morpliologie der Miss- 
bildungen., 1912, Part III, p. 675. Greig, D. M.: Edinburgh M. J. 38: 341, 1931. 
Eeidl&r, E.: Wien. kliu. Wchnsehr., No. 5, 114, 1924. Ingalls, N. W.: 1. Quart. 

Rev. Biol. 7: 47, 1932. 2. Am. J. Path. 8: 525, 1932. Kehrer, E.: Monatschr. 

f. Geburtsh. u. Gynak. 31: 183, 1910. Lundwall, K.; Arch. f. Gynak. 130: 487, 
1927. Mall, F. F.; J. Morph. 19: 1, 1908. Mall, F. F., and Meyer, A. W.: 
Contrib. to Embryology 12: No. 56, 1921. Streeter, G. L.: Contrib. to Embryol- 
ogy 22: No. 126, 1, 1930. TerniJin, E.: Arch. f. Gynak. 140: 428, 1930. Wals, 
W.: Monatssch. f. Geburtsh. u. Gjmak. 65: 167, 1924. Elirenfest, E.: Birth Injuries 
of the Child, ed. 2, 1931, D. Appleton & Co. 


HYSTEEOSTOMATOMY* 

Lawrence M. Randall, M.D., Rochester, Minn. 

(From the Section on Obstetrics, The Mayo Clinic) 

I NCISION of the incompletely dilated vaginal portion of the uterine 
cervix in labor was first definitely introduced by Diihrssen, in 1890. 
With the development of analgesic agents, together ivith improvement 
in the technic of abdominal cesarean section, the indications and ne- 
cessity for this operation were gTeatly reduced. The procedure, how- 
ever, has certain well-defined indications, and a definite, if limited, 
field of usefulness. A number of factors have been mentioned as 
etiologie when dystocia exists. 

Conditions of the eeiwix are as follows: Rigidity, ivith insufficient 
elasticity to allow dilatation, a condition which is presumed to be not 
uncommon among elderly primiparous women; fibrosis, which may be 
a result of preexisting chronic infection, with or without the added 
efi’eets of such factors as too extensive treatment by cauteiy; old, ex- 
tensive laceration, with attendant excess of scar tissue that does not 
yield under the influence of the uterine contractions ; conglutination of 
the external os ; previous operative procedures, such as high amputa- 
tions or extensive trachelorrhaphy. 

Anomaly of the powers of expulsion exists when contraction and 
retraction of the uterine musculature is not sufficient .to. accomplish 
obliteration of the cervical canal, and subsequent dilatation of the 
external os. 

Disproportion between the size of the presenting part and the bony 
canal of the pelvis may lead to inability of the presenting part and 
bag of waters to act effectively on the cervix. 

Anomalies of position and presentation of the fetus may exist, such 
as occipitoposterior positions' and face presentations. 


Submitted for publication June 8, 1932. 



874 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


Conditions associated with, the amniotic sac are as follows: pre- 
mature rupture of the membranes ; abnormally tough membranes with 
delayed rupture; the so-called pathologic membranes, wherein the 
membranes are closely applied to the presenting part, with no fore- 
waters to act as a dilating wedge, and adhesion between the mem- 
branes and the cervix in the region of the external os. 

As far as the cervix itself is concerned, it would seem that the fac- 
tors of consistence, thickness, and length, would determine the resist- 
ance to be offered to effacement of the cervix, and to dilatation of the 
cervical canal and external os. If the cervix is firm, scarred, hyper- 
trophied, indurated, or badly infected, with resultant increase in firm, 
fibrous tissue, it might be presumed that more uterine contractions 
would be necessary to cause complete effacement and dilatation of the 
cervix. HoAvever, this does not necessarily follow, for one not infre- 
quently notes, during the progress of pregnancy, a change in con- 
sistence of the cervix ; it becomes soft, and with the onset of labor di- 
lates with normal rapidity. 

Probably conditions of the cervix in themselves are not as fre- 
quently the cause of failure of dilatation as are factors related to the 
powers of expulsion and the fetus. One of the most difficult things 
to evaluate in obstetric practice is the efficiency of a uterine contrac- 
tion. What effect the contraction and retraction of the uterine muscle 
will have on a given cervix is unknown until trial of labor begins. It 
is also probable that the intensity of a given pain, as measured by 
palpation, is of more value in determining this point than the fre- 
quency or duration of the pains. A patient may have twenty pains 
in one hour, of the same duration as those of another parturient 
woman, who is having twelve pains an hour, but accomplish less. It 
has been stated by Calkins and his associates that accurate determina- 
tion of the effectiveness of the labor pain, balanced against the resist- 
ance of the eemdx and pelvic floor, is the all important factor in de- 
termining the length of labor. As is evident, effectiveness of uterine 
contractions is related to the retractive effort and the interval of re- 
laxation between pains, as well as to the active stage of contraction. 
This is easily proved by the effect of analgesic agents during the 
course of the first stage of labor. Pains may be almost continuous 
and intense, as measured by palpation during the contraction, but 
progress in effacement and dilatation may be verj'- slow. After ad- 
ministration of sufficient sedative to increase the interval between eon- 
ti’actions, and so to allow an interval of relaxation, the cervix is 
rapidly dilated. How much actual relaxing effect there may be on 
the cervix is difficult to determine. 

The effect of disproportion, and of anomalies of presentation and 



• RANDALL ; HYSTBROSTOMATOMY 


875 


position, on effacement and dilatation of the cervix, is apparently one 
of inability of the presenting part, and of the amniotic sac, to apply 
themselves to the cervix sufficiently to carry out the usual dilating, 
wedge-like effect. 

The effect of the hydrostatic dilating wedge on dystocia due to the 
cervix is inconstant. It has long been taught that premature rupture 
of the membranes in itself often leads to a long first stage of labor. 
Statistical studies have appeared which tend to refute this teaching. 
Randall and Schulze have both shown that, given a well-flexed vertex 
presentation with the occiput in the anterior half of the pelvis, with- 
out disproportion, labor is often shorter than the average. Dry labors 
that are long and drawn out are most frequently associated with some 
other complication, such as an occipitoposterior position, or dispro- 
portion between the presenting part and the pelvic canal. The so- 
called pathologic membranes, when the presenting part fits into the 
amniotic sac, with no forewaters, is not infrequently seen in cases in 
which the first stage of labor is slow; in these eases, rupture of the 
membranes is frequently succeeded by progress of labor. Abnormally 
tough membranes are occasionally encountered, as well as adhesions 
between the tissue surrounding the external os and the membrane ad- 
jacent to it, and may result in a slow first stage of labor. 

Among 3,200 confinements on this service at The Mayo Clinic the 
uterine cervix offered definite obstruction to the progress of labor 
sufficient to warrant hysterostomatomy (incision of the vaginal por- 
tion of the cervix) in twelve. Dystocia due to incomplete dilatation 
of the cervix is probably less common than that due to other causes. 
This relative infrequence is no doubt due largely to the general prac- 
tice of conservative obstetrics and the increasing use of analgesic 
agents in the first stage of labor. 

The average age of this group of 12 patients was twenty-nine years ; 
the oldest patient was aged thirty-six years and the youngest, twenty- 
two. One patient gave a history of late onset of menses and had been 
told previously that her uterus was underdeveloped; when seen by 
me she had been pregnant seven months, and there were multiple 
fibromyomas in the uterus. These tumors did not obstruct the birth 
canal. None of the patients gave histories of previous pelvic inflam- 
matory disease or operative procediu’es on the genitalia. 

The measurements of the pelvis of 9 of the 12 patients were within 
normal limits. Of the remaining 3, one had an estimated obstetric 
conjugate of 10 cm., and rather heavy pelvic bones. In 2 eases there 
was anteroposterior shortening of the pelvic outlet, and in one of 
these the spines of the ischium were prominent and both the inter- 
tuberal and the interspinal diameters were shortened. 



876 


AaiERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


The pregnane}^ had reached temi, except in one ease. In this case 
labor ivas induced at thirty-fonr iveeks hecanse of severe toxemia of 
the later months of pregnanes'-. 

There were 11 primiparas (8 of these were primigravidas) and one 
was a multipara. Of the 3 primiparas who were mnltigravidas 2 re- 
ported previous miscarriages, with nneventfnl convalescence, and one 
of these 2 had also had an extranterine pregnancj’; the third patient 
had been delivered of a macerated fetus of twenty-four weeks without 
complication of labor or puerperium. The multipara had been deliv- 
ered spontaneously at term nine s'ears previously. Her postpartum 
course had been without incident. Operation for cholecystitis and 
appendicitis had been performed three years prior to this pregnancy. 
Nine of these 12 patients received prenatal care under my supendsion 
and 3 were admitted to the hospital as emergenej’- cases. 

There were 2 patients with toxemia of the later months of preg- 
nancy. In one of these eases there was severe preeclamptic toxemia, 
and the patient was seen as an emergenej' ease at term. In the other 
ease there was a similar condition, and the patient was seen as an 
emergenej'- case in the thirty-fourth week; eclamptic convulsions de- 
veloped after induction of labor bj-- means of a Voorhees hag. 

Labor was induced in one case with castor oil and quinine at term, 
and in 3 cases a Voorhees bag was inserted into the cervix. Two of 
the inductions bj’- means of a bag were done in the presence of severe 
toxemia, one at thirtj'-four weeks of gestation and one at term, and the 
third induction was for the multigravida, who was at term. She had 
had labor pains for ten daj'S before admission, with no evidence of 
cervical dilatation. This patient was considerahty exhausted. Since 
a quarter of a grain of morphine hypodermically had no ameliorating 
effect on the pain or on the progress of labor, it was thought advisable 
to insert the bag. 

Premature rupture of the membranes complicated 3 cases. In 2 
cases the membranes imptured at the onset of labor, and in one case 
thej^ had ruptured forty-eight hours before the onset of labox*. 

The average length of labor before interference was forty-one hours, 
excluding that case in which the patient had had uterine contractions 
for ten daj’-s prior to admission. The longest first stage was fifty-five 
and three-fourths hours and the shortest, twenty-five and a half hours. 
In each case, complete effacement of the cervix occurred before inter- 
ference was attempted. The amount of dilatation varied from 3 to 
7 cm., an average of 4.4 cm. at the time of incision. 

The second stage of labor averaged forty minutes in length; the 
longest second stage was one hour, and the shortest, nineteen minutes. 
The thii’d stage of labor averaged eleven minutes in length ; the long- 
est time was fifteen minutes and the shortest, nine minutes. In each 



RANDALL. ; HYSTEROSTOM ATOMY 


87T 


instance the placenta was delivered by early expression after spon- 
taneous separation and delivery from the nterns into the vagina. 

Episiotomy was done in each case except the one case of the mnlti- 
gi'avida. In one case the perineum was “ironed” out before the episi- 
otomy was performed. 

The presentation was vertex in each instance. There were 5 eases 
of occipitoposterior positions, in 3 of which the position persisted and 
in 2 of which rotation became arrested deep in the pelvis, in the 
transverse diameter. In the cases of persistent occipitoposterior posi- 
tion, manual rotation Avas necessitated in tAvo, and spontaneous rota- 
tion oecuiTed in one after incision of the cerAux. Manual rotation cor- 
rected one deep transA^erse arrest, and in the other Barton forceps 
were used. 

Delivery AAms accomplished by forceps extraction in each ease ; in 
8 cases mid forceps, and in 4, Ioav forceps operations Avere done. 

The aA'^erage AA’^eight of the infants, excluding' the premature infant, 
Avhieh Aveighed 3 pounds and 9 ounces, Avas 7 pounds ; the largest baby 
Aveighed 9 pounds and 2 ounces, and the smallest 6 pounds and % 
ounce. The baby AAdiich Aveighed 9 pounds and 2 ounces Avas borne by 
a patient AAdiose ischial spines Avere prominent, and naiTOAved the 
plane of smallest dimension definitely. A baby of 8 pounds and 12 
ounces Avas borne by the oldest patient of the series (thirty-six j'-ears 
of age) Avho had normal pelvic measurements. A baby of 8 pounds 
and 9 ounces Avas bome by another patient, Avhose pelvic measure- 
ments Avere normal. An infant Aveighing 8 pounds and 12 ounces Avas 
delivered after arrest of rotation had occurred. 

The puei’perium Avas uneventful in 9 cases. The remaining three 
patients had complications as folloAvs; one patient had had persistent 
jaundice during pregnancy, AAdiich had necessitated repeated duodenal 
drainage, and she came to deliver}'- in rather poor general condition,- 
she had a temperature of 102° P. on the second day after delivery but 
Avas subsequently afebrile. The patient aaOio had eclamptic convul- 
sions had a temperature of 102° P. tAvo days before delivery, asso- 
ciated Avith an eclamptic convulsion. She remained afebrile after de- 
livery until the tAvelfth and thirteenth day, Avhen the temperature rose 
to 101° P. succeeded by normal temperature. One patient had a 
temperature of 101° P. on the seventh day and a chill and tempera- 
ture of 105° P. on the eighth day, a drop to 101° P. on the ninth day, 
and a subsequent normal temperature. There had been retention of 
urine necessitating catheterization on the second, third, and fourth 
days after deliveiy. This recurred on the eighth, ninth and tenth 
days. With the establishment of spontaneous -urination and the dis- 
appearance of residual urine in the bladder, the temperature remained 
normal. 



878 


AjMERICAN journal of obstetrics and gynecology 


In this group of twelve patients, eight were able to void spontane- 
ously throughout the course of the puerperium. Pour patients 
were catheterized, two for retention and inability to void, and two 
because of residual urine. One patient with retention has 
been mentioned, and for the other catheterization was necessary for 
the first seven days, after which spontaneous, complete emptying of 
the bladder occurred. In one ease in which there was residual urine, 
the amount was reduced to 60 c.e. on the fifth day, and subsequent 
catheterization was unnecessary. Another patient had 500 e.c. of 
residual urine for the first two days, but was subsequently able to 
empty the bladder completeljL Each patient was examined by rec- 
tum before dismissal, at which time there was no evidence of pelvic 
inflammatoiy disease. In ny opinion there were no postpartum com- 
plications attributable to the type of labor or deliveiy. 

PROCEDURE 

Complete effacement of the uterine cervix is an essential condition 
for performance of hysterostomatomy. If this has not occurred, there 
has not been complete retraction of the parametrial tissue containing 
the blood vessels and ureter, and extension of the incision may result 
in injury to the vessels, with dangerous hemon’hage. 

The presenting part must be engaged. A nonengaged presenting 
part, even though definite pelvic contraction cannot be demonstrated, 
contraindicates this procedure. The bladder and rectum should be 
empty. 

The incisions in the cervix were made at points corresponding to 
10 :00, 2 :00 and 6 :00 o ’clock on the periphery of the external os in 
five cases, and at 10 :00 and 2 :00 o ’clock in four cases, and at 6 :00 
o’clock in only three cases. The site and extent of the incisions de- 
pended on the conditions present. In those cases in which only the 
posterior incision was made, the cervix had a very long posterior lip. 
In two cases, this operated actually to hold the presenting part from 
descent into the pelvis, and directed it toward the pubis instead of 
along the nonnal axis of the birth canal. With incision of the cervix, 
the presenting part reached the pelvic floor with the next few pains. 
In the eases in which incision was made at the positions 10:00 and 
2:00 o’clock, the amount of dilatation was sufficient to have allowed 
manual dilatation to a diameter of 5 to 7 cm., but the ceiwix was firm 
and inelastic, and manual dilatation would have amounted to manual 
laceration. In these cases, as with an inelastic perineum, it was felt 
that a clean incision was preferable to laceration. The incisions at 
10 :00, 2 :00 and 6 :00 o ’clock were performed in those cases in which 
there was dilatation of the external os of 3 to 5 cm. ; in such instances 
possibility of extension of the incisions is more to be considered than 



RANDALL ; HYST35ROSTOMATOM\' 


879 


in those instances in which thei'e is greater dilatation. A tentative 
attempt may be made to dilate manually, but in my opinion, if cervi- 
cal incisions are to be made at all, they should be a primary procedure. 
Unsuccessful manual stretching leaves the cervix traumatized and 
edematous. Extension of incisions made following this are more 
likely to occur, repair is more difficult, and proper healing is inter- 
fered with. 

After complete effacement of the cervdx and engagement of the pre- 
senting part has occurred, the incisions are made as follows ; 

The patient is given sufficient anesthesia to relieve discomfort, but 
surgical anesthesia is avoided, for it is desirable to preserve uterine 
contractions. In the interval between pains the cervix is immobilized 
with a smooth forceps, but undue compression is avoided, in order to 
lessen injuiy to the tissues. Under guidance of the finger, the incision 
is then made at 6 ;00 o ’clock to the vaginal fornix. If a pain occurs, 
the presenting part is restrained to prevent descent and possible ex- 
tension of the incision. Between the next two contractions incisions 
are made at 10:00 and 2:00 o’clock. The patient is now allowed to 
have several uterine contractions. These usually have the effect of 
pushing the presenting part through the cervix and down to the pelvic 
floor. Delivery can then be accomplished by means of forceps, Avith- 
out danger of extending the incisions during application and traction. 
Delivery by forceps is probably preferable, for continued expulsive 
efforts on the part of the mother might produce extension of the in- 
cisions. There was no undue bleeding following the incisions in any 
case in my experience. 

Repair . — The cervix is repaired after delivery of the placenta. To 
repair before this time renders exposure difficult and the subsequent 
extrusion of the placenta through the repaired cervix may interfere 
with the integrity of the suture line. The loAver extremity of each 
side of the individual incision is grasped Avith a smooth forceps. Trac- 
tion on the forceps, combined Avith retraction by the assistant, and 
pressure on the fundus above the pubis alloAvs the upper angle of the 
incision to be brought into vieAV and the tissue in this region accu- 
rately approximated. Interrupted mattress sutures of No. 2, twenty- 
day chromic catgut are inserted. The upper suture should include 
tissue above the upper angle of the incision to avoid the possibility of 
secondary hemorrhage. The remainder of the incision is then closed 
Avith three or four intenmpted mattress sutures, the lower one ap- 
proximating the edge of the external os. These sutures should be 
tight enough to close the incision, but not too tight, since necrosis in 
the Icnot may occur and interfere wdth healing. 



880 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


Postpartum care does not differ from that usually foUoAved. The 
patients are allowed to sit up on the eighth day after delivery, to 
be out of bed on the ninth daj’-, and to go home on the tenth to twelfth 
day if they live in the immediate vicinity. 

POSTPARTUM RESULTS IN TWELVE CASES 

Case 1. — Six weeks after delivery the episiotomy wound was well healed, the 
perineum was competent and the ceivical incisions were well healed although 
there was an adhesion between the vaginal wall and the incision at 2:00 o’clock 
position. The os was small and clean. The uterus was well supported in good 
position and the adnexa were negative to examination. 

Case 2. — Six weeks after delivery the perineum was competent, the episiotomy 
wound was well healed and the cervical incisions were completely healed. The os 
was small and clean. The uterus was well supported and the adnexa were nega- 
tive to examination. 

Case 3. — Eight weeks after delivery the result was excellent except that the 
posterior incision had not united, to a depth of 1 cm. The edges were clean. 

Case 4. — Eight weeks after delivery the result was excellent. There was a 
slight depression at the site of the incisions at 10:00 and 2:00 o’clock. Cer- 
ricitis was graded 1. 

Case 5. — The patient did not return for postpartum examination. 

Case 6. — There was separation of the incision at the position of 2:00 o’clock 
to a depth of 1 cm. 

Case 7. — Ten weeks after delivery the perineum was relaxed to Grade 1. There 
were lacerations about 0.5 cm. in depth at the incisions in the position of 10:00 
and of 2:00 o’clock. The cervix was clean. 

Case 8. — Eighteen weeks after deliver}' none of the incisions had healed. There 
was complete laceration of the cervix to the fornices. 

Case 9. — The patient did not return for postpartum examination. 

Case 10. — Seven weeks after delivery the incisions were w'ell healed. Cervicitis 
graded 3' was present with extropion. This condition was treated with eauter}' 
with satisfactory results. 

Case 11. — Six weeks after delivery the j)osterior incision was separated to a 
depth of 1.5 cm. The edges were clean. 

Case 12. — Four weeks after delivery the result was excellent. 


COMMENT 

It is difficult to establish exact causes for these 12 cases of cervical 
dystocia. Most of the causes of this condition enumerated earlier in 
the paper would not seem to apply. The onlj^ previously existing 
pelvic condition, multiple uterine fibromyomas, could be used as an 
explanation for one case. Besides this we were attempting to open 
an unprepared cersdx in a primigravida six weeks before term. Per- 
haps if the condition of the patient had not been precarious on ac- 
count of the severe toxemia, moi*e time could have been taken and 
spontaneous dilatation might have occurred. In the remaining 11 
cases, however, sufficient time would seem to have been allowed for 
spontaneous dilatation. It should be pointed out that the dilatation 
in each case remained stationary for several hours before interference 



KANDAL.L : HYSTEROSTOMATOMY 


881 


was decided on. Tliese patients liad an adequate amount of time with- 
out analgesia to accomplish opening of the cervix in the usual case. 
They also passed through a period of time in which sufficient anal- 
gesia was given to produce definite relief from pain, and the interval 
between pains was definitely increased with little effect on the amount 
of dilatation, conditions which, as a rule, lead to complete effaeement 
and dilatation of the cervix. There is no doubt that employment of 
analgesic agents in the first stage of labor is of great aid in securing 
effaeement and dilatation of the cervix. The average patient, besides 
receiving relief from pain, secures enough relaxing effect to shorten 
the period of dilatation. Personally, I believe this is due to increased 
efficiency of the uterus rather than to actual relaxing effect on the 
cervix. 

It is perhaps significant that in 5 of these 12 eases, the fetus was in 
the primarj’’ occipitoposterior position. This is in keeping with the 
fact that in cases in which this complication occurs, first and second 
stages of labor usually are longer and more painful than in eases in 
which the occiput is primarily in the anterior half of the pelvis. 

CONCLUSIONS 

Hysterostomatomy is of limited but definite usefulness. It should 
not compete in the mind of the obstetrician with cesarean section. The 
cervix should be completely effaced and the presenting i)art should 
be engaged if the operation is to be attempted. These conditions 
should be adhered to rigidly. Disproportion at the pelvic outlet is not 
of so much importance, although successful vaginal delivery should 
be expected before the operation is undertaken. 

The operation is not justified as a rule until more than usual time 
has been allowed for spontaneous dilatation to occur. In the course 
of this time, there should be a period when sufficient sedatives had 
been employed to secure a definite period of rest for the uterus and 
for the patient. 



THE roPILLA BY TEST FOB THE DIAGNOSIS OP PBEGNANCY 

Based on the Observation op 382 Patients 

Z. Bercovitz, M.D., Pyengyang, Chosen. 

(From the Department of Laboratories and Department of Gynecology, New YorTc 
Post-Graduate Medical School and Hospital) 

T he object of this report is to record the progress ivhieh has been 
made in the study of the diagnosis of pregnancj'- by the simple 
technic of instilling the patient’s blood into her own conjunctival sac 
and noting whether or not a change takes place in the size of the 
pupil. During this investigation 382 patients have been observed. 

In a previous report^ attention was directed to the fact that if the 
blood of a pregnant woman is withdrawn and rapidlj^ centrifuged, 
the clear serum obtained therefrom instilled into her own conjunctival 
sac will cause an alteration in the size of the pupil. This change is 
either a dilatation or contraction, contrasted with the control pupil, 
occurs promptly, and in some cases lasts for several minutes. A simi- 
lar reaction does not occur in nonpregnant women or in men, but it 
was noted that when the serum from a pregnant woman causes a 
change in her own pupil, it will also excite the same reaction of the 
pupil in nonpregnant women, men, rabbits, and cats. Serum which 
was stimulating to the pupil when withdrawn from the patient lost 
its activity after about two hours. 

One of the difSculties in the original procedure was the necessity of 
securing 5 c.c. of blood and centrifuging for varying periods of time, 
until clear serum was obtained. The substitution of whole blood for 
serum, therefore, seemed highlj'- desirable, if it could be utilized with- 
out affecting the reliability of the test. Several drops of whole blood 
were mixed with an equal amount of normal saline solution and the 
mixture instilled into the conjunctival sac of the patient from whom 
the blood was taken. There was a prompt, definite change in the size 
of the pupil, indicating a positive reaction, in a sufficient number of 
eases to demonstrate the feasibility of dispensing with centrifuging 
the specimen. Nonpregnant individuals were also tested and all of 
them failed to show any reaction. In some instances rapid blood clot- 
ting caused inconvenience, so a 10 per cent solution of sodium citrate 
was satisfactorily substituted for the normal saline solution. 


^Bercovitz, Z.: AM. J. Obst. & GTNec. 19: 7G7. 1930. 



BERCOVITZ; PUPILIiARY TEST FOR PREGNANCY 


883 


SIMPLIFIED TECHNIC 

The only apparatus required includes a small lancet for obtaining blood, a small 
receptacle, such as a hollow- gi'ound glass slide, a medicine dropper, and a 10 per 
cent solution of sodium citrate. One drop of the sodium citrate solution is mixed 
with five or six drops of blood from the finger or ear, and the mixture immediately 
instilled into one eye of the patient. Instead of using a receptacle for mixing, 
a small glass pipette with a rubber bulb or a medicine dropper may be found 
convenient. A drop or two of the 10 per cent sodium citrate is taken up in the 
pipette and the blood then aspirated in the same way. These are then mixed and 
quickly instilled into the eye and the results observed. The .pupils are examined 
with the patient looking at some object about six inches distant in order to note 
if the pupils are equal and regular. It is best to have the patient in a partly dark- 
ened room with a soft yellow light above and behind her. Tliis method of 
illumination has proved universally satisfactory. It illuminates the eyes sufficiently 
and does not shine directly into the eyes causing a pupillary reaction to light. 
Wlien the patient accommodates her vision to some nearby object the results are 
more uniform than when she makes an effort to relax the pupils to focus on one 
placed at a distance. If accommodation is adjusted to a near object, even if the 
pupillary reaction is manifested by a positive contraction of the pupil, the difference 
in size of the untested pupil is easily recognized. It is wise to make a preliminary 
test before instilling the eitrated blood, to establish a basis for comparison after it 
has been dropped into one eye. Following the above described technic the pupillary 
reaction is prompt. One of two distinct reactions may be noted. One is dilatation 
and the other is contraction, either of which may be evident when the test eye 
is compared with the control pupil. The change in the size of the pupil is always 
sufficiently marked to be recognized and usually lasts for several minutes before 
returning to normal. 

The test requires about two minutes, is clean and simple, and causes 
the patient little inconvenience. In over three hundred patients there 
has not been a single instance of complaint of pain in the eye or con- 
junctivitis. It should be emphasized that before carrying out this 
procedure both pupils should be carefully studied before the instilla- 
tion is made. After dropping the eitrated blood into one eye, both 


Table I. — ^Eesults in Nonpkegnant Individuals 



NUMBER OP 

PATIENTS 

POSITIVE 

PvEACTIONS 

NEGATIVE 

REACTIONS 

Saline and Wliole Blood 

Dr. Z. Bercovitz 

19 

0 

19 

eitrated Whole Blood 

Dr. Z. Bercovitz 

63 

0 

63 

eitrated Whole Blood 

Dr. John e. Du Bois 

14 

0 ’ 

! 14 

eitrated Whole Blood in Men 
Dr. Z. Bercovitz ' 

16 

9 

16 

Citrated Whole Blood 
(in Korean Women) 

Dr. Z. Bercovitz 

25 1 

! 

0 

25 

eitrated Whole Blood 
(in Korean Women) 

Dr, A. E. Leadbeater 

17 

(.) 

1 

17 

Total 

154 

0 

154 


884 


AJIERICAK JOURNAL OP OBSTETRICS AND GYNECOLOGY 


eyes should be compared to determine if any change occurs on one 
side as contrasted ivith the other. Definite alteration in the size of the 
pupil of the tested eye -without a similar reaction on the opposite side 
constitutes a positive reaction. 

Results in Nonpregnaut Patients . — One hundred and fifty-four pa- 
tients -were included in the group of nonpregnant individuals, and 16 
of them -were men. The pupillary test was negative in all eases (Table 
I). Most of the subjects were selected from the clinical material in 
the Gynecological clinics of the New York Post-Graduate Medical 
School and Hospital. The cases included a variety of conditions, 
salpingitis, ovarian disease, endocrine disturbances with amenorrhea, 
and induced and natural menopause. These patients were examined 
at different stages of the menstxmal cycle and some were actually men- 
struating. Not a single false positive reaction was observed. 


Table II. — Results in Pregnant Women 


NAME OF DOCTORS 

NUMBER 

OF CASES 

POSITIVE 

REACTIONS 

PER CENT 

POSITIVE 

REACTIONS 

NEGATIVE 

REACTIONS 

QUESTIONABLE 

REACTIONS 

Dr. W. Woodrow 

69 

57 

82.6 

6 

6 

Dr. John C. Du Bois 

11 

10 

90.9 

1 

0 

Dr. A. E. Leadbeater 

S 


84.2 

0 

1 

(in Korean women) 
Dr. Z. Bercovitz 

88 

■■ 

84.2 

8 

5 

Dr. Mary W. New 

7 


85.8 

0 

1 

Total 

183 

155 1 

84.7 

15 

13 


Results in Pregnant ^Yomen . — The pupillaiy test for pregnancj'- was 
applied in 183 women in whom the diagnosis of pregnancj’’ was finally 
confirmed. Of the 183 patients observed 155, or 84.17 per cent, showed 
a positive pupillary reaction (Table II). The patients tested by Dr. 
W. Woodrow and Dr. Z. Bercovitz were found in the Prenatal Clinics 
of the New York Nursery and Child's Hospital; those tested by Dr. 
John C. Du Bois were in the Clinic of Professor Walter T. Dann- 
reuther in the New York Post-Graduate Medical School and Hospital. 
Dr. A. Evelyn Leadbeater’s observations were in Korean women at 
the Pyongyang Union Christian Hospital, Pyengjmng, Chosen (Korea) . 
Seven cases were contributed by Dr. Mary W. New and taken from 
her private practice in Seoul, Korea. 

In the series collected by Drs. Woodrow and Bercovitz many of the 
patients were under treatment for syphilis, but this did not seem to 
alter the reliabilit 3 ’ of the test nor eventuate in eye injurj’-. 

Thirteen reactions were regarded as questionable because it was 
not possible to ascertain definitelj’- that the test was positive, although 
it seemed positive. 













BERCOVira: PUPIEEARY TEST FOR PREGNANCY 


885 


Results in Questionable Case of Pregnancy. — Observations were made 
in 40 patients ; most of these were examined by Dr. John C. Du Bois in 
Professor Dannreuther's clinic in the NeAv York Post-Graduate Medi- 
cal School and Hospital. Three cases were added by me and 7 are 
included through the kindness of Dr. Mary W. New. This group is of 
particular interest because it summarizes some of the diagnostic prob- 
lems confronting the physician. In several eases the pupillary be- 
havior was the first evidence of the presence or absence of pregnancy. 
Twenty-one finally proved to be pregnant. Thirteen were not preg- 
nant, and 6 did not return for further observations. One pregnant 
patient showed a positive pupillary reaction twelve days after the on- 
set of her last menses. Another shoAved a positive reaction at sixteen 
days, and others at thirty-six, thirty-eight, forty-three, and forty-four 
days after the last menstrual period. In 4 of Dr. Noav’s patients, there 
Avas definite oscillation of the pupil as compared Avith the control. 
This reaction Avas described in the first report and is indicative of a 
positive reaction. Those who Avere not pregnant failed to demon- 
sti’ate any reaction. 

A positive pupillary test is especially valuable evidence of preg- 
nancy AAdien correlated AAuth the history and physical findings. 

The Pupillary Test After Parturition. — ^Postpartum tests Avere made 
in 41 patients, AAdth negative reactions in 34. In 7 cases the positive 
reaction persisted. One patient aa'Iio manifested a positive I’eaetion 
before labor shoAved a loss of I'esponse fifteen minutes after the de- 
livery of tAvins. 

The Effect of Phenol on the Pupillary Reaction. — ^Using a solution of 
0.2 per cent phenol in normal saline solution, a group of patients Avere 
examined to determine if the phenol in the conjunctival sac Avould 
change the pupillary reactions in pregnant Avomen. 

A solution Avas prepared by mixing 3 c.c. of 1-1000 adrenalin hy- 
drochloride with 1 c.c. of normal saline solution. This AAms instilled 
into the conjunctival sac of 5 pregnant Avomen and in each instance a 
positive pupillary reaction occurred. Another solution Avas prepared 
by using the same amount of adrenalin hydrochloride, but instead of 
using normal saline, the 0.2 per cent phenol-saline solution Avas em- 
ployed. After instillation of this mixture into the eye of the same 
patients no pupillary reaction took place. In 3 patients, during the 
course of a positive reaction induced Avith AAdiole blood, one minim of 
the phenol-saline mixture dropped into the conjrmctival sac immedi- 
ately abolished the reaction. In 3 other cases AAdiich had previously 
reacted positively AAuth blood, the test Avas repeated after first instill- 
ing the 0.2 per cent phenol-saline solution. No reaction occurred. It 
is therefore apparent that phenol instilled into the conjunctiA^al sac, 
either before or during a pupillary reaction resulting from adrenalin 
or the patient's OAvn blood, abolishes the reaction. 



b86 


AJVIEKICAN JOUHNAIj OF OBSTETRICS AND GYNECOLOGY 


The Pupillary Reactions Follotoing the Instillation of Female Sex 
Hormone. — Through the eoui'tesy of Dr. Hariy B. Van Dyke, of the 
University of Chicago, I received a solution containing an extract of 
“female sex hormone,” -which had been isolated from the urine of 
pregnant women. This extract was neutralized and then tested in 
the conjunctival sac of 14 pregnant women. No positive reactions 
were observed in any case. The same patients were then tested with 
their own blood and reacted positively. The neutralized extract was 
then injected into mice in conformity with the technic of Aschheim 
and Zondek. In all of the mice the Aschheim-Zondek test was posi- 
tive. However, neutralized extract of female sex hormone will not 
reproduce the same reaction in the pupil of pregnant women as that 
produced by their own blood. 

Sufficient evidence is at hand to warrant further investigation of 
the reaction in both clinical practice and animal experiments. Fur- 
ther research may establish a relationship between abortion and the 
pupillary reaction of pregnancy. The pupillaiy test should be eval- 
uated in cases of ectopic pregnancy. The influence of the placenta on 
this reaction should be determined, as I have not ascertained whether 
the pupillary reaction is negative fifteen minutes after delivery of 
both infant and placenta. 

I am now located in a mission hospital in Korea and have neither 
the clinical nor laboratory facilities for further research. Others 
moi’e fortunately situated may pursue these studies to their logical 
conclusions. 

SUMMARY AND CONCLUSIONS 

1. The pupillaiy reactions of pregnant women, nonpregnant women, 
and men have been studied. 

2. One drop of 10 per cent sodium citrate solution is mixed with 5 
or 6 drops of the patient’s blood and instilled into one eye. The 
other ej^e is used for control observation and comparison. 

3. The test requires about two minutes and the reaction usually 
lasts for about five minutes. 

4. Observations in 382 patients constitute the basis of this presen- 
tation. 

5. One hundred and fifty-four individuals were not pregnant, and 
none of them showed a positive pupillary reaction. Sixteen of this 
group were men. There were no false positive reactions. 

6. In 183 patients the diagnosis of pregnancy was confirmed by sub- 
sequent events. Of these, 155 or 84.7 per cent showed positive pupil- 
lary reactions. In one of them a positive pupillary reaction was found 
twelve days after the onset of the last menstrual period. 



PECK AND GOLDBBRQER: UTERINE BLEEDING 


887 


7. Forty -one postpartum cases were observed. Thirty -four bad nega- 
tive pupillary reactions. One patient who bad a positive reaction be- 
fore delivery was negative fifteen minutes after tbe delivery of twins 
and tbe placenta. 

8. A 0.2 per cent pbenol in normal saline solution will prevent or 
abolish a pupillary reaction of pregnancy. 

9. Neutralized female sex hormone, isolated from the urine of preg- 
nant women, failed to cause a pupillary reaction when instilled into 
the conjunctival sac of 14 pregnant women. All of these women re- 
acted positively to their own blood. 

10. A positive pupillary test is of great diagnostic value when cor- 
related with the history and physical findings. The test should be 
used in all doubtful cases, even though it has not yet established a 
means of positive differential diagnosis between pregnancy and all 
other conditions. 

The author wishes to express his indebtedness to Dr. Ward J. MacNeal and his 
state in the Department of Laboratories, and Dr. Walter T. Dannreuther and his staff 
In the Department of Gynecology in the New York Post-Graduate Medical School and 
Hospital for their cooperation, courtesies, and provision of the necessary facilities 
for this investigation. 


THE TREATMENT OF UTERINE BLEEDING- WITH SNAKE 
VENOM (ANCISTRODON PISCIVORUS) 

Samuel M. Peck, M.D., and Morris A. Goldberger, M.D., P.A.C.S., 

New York. N. Y. 

(From the Division of Laboratories and the Gynecological Service of Mount Sinai 

Eospital) 

S uccessful attempts at nonspecific control of experimental pur- 
pura in animals’- led Peck to treat patients suffering from hemor- 
rhagic diathesis with sualce venom. The observation was made that in 
women with thrombocytopenic purpura, the prolonged menstrual flow 
was checked. This led him to suggest that patients with prolonged 
uterine bleedings of various types might be treated with this therapeutic 
agent. A preliminary report was published.-- ® The eases reported in 
this communication were chosen for snake venom injection because of 
the failure of other forms of therapy during a long period of observa- 
tion. 


METHOD OF ADMINISTRATION 

The venom was used in. 1:3000 dilution with sterile normal sodium chloride 
solution containing 1:10000 mertWolate. The venom -was obtained through the 
courtesy of the Antivenin Institute of America (Mulford Biological Laboratories). 
It was g iven intradermaUy. The initial injection was 0.2 c.c. and subsequent injec- 


Submitted for publication, June 22, 1932. 



888 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


tions were 0.4 c.c., given twice weekly. In this series of cases the therapy was 
continued for from three to six months. It is advisable to treat patients for at least 
three months even in the presence of marked clinical improvement before any conclu- 
sions are drawn as to the efficaej’ of the treatment. For the first five or six injections 
care should be taken that at least 10 cm. separate the injection sites from one an- 
other. It has been our rule to use the left arm, right arm, right thigh, left thigh, 
etc. 

Figs. 1 to 5 schematically represent uterine bleeding: in five of the cases treated 
with venom. The abscissae divide the schema into scant, moderate, and profuse 
bleeding. 


SEPT OCT. inv MC J;lM. US. UAS APR. HAT JJOT 



6 JOIUHS BEF0H2 TRHATICNT IIJRINO TREATUENT 


Pig. 1. — Case 6, Table I. D. G.. nineteen years old. Single. Hgb. 18 per cent. 
Transfused 2 x. Curetted 2 x. 


Wlf* JUtT MPT. OCT. KOV. J*C. JAN >tA*. iffi. H4Y 



BZrORS TRZATUSIT HJRINC TPZATICNT 


Fig. 2. — Case 2, Table I. M. J., twenty years old. Married. Hgb. .50 per cent. 
Transfused 2 x. Curetted 3 x. 


JULY Airo sen oct nov mc Jan *ub. ipr. iuy jw* 



7 ICKIHS Brpsrs TTaiTVSW lOTWC TFSATUm 


Fig. 3. — Case 5, Table I. A. C., fourteen years old. Hgb. 32 per cent. Trans- 
fused 4 X. Curetted 1 x. 

In some of the patients after 4 or 5 injections, a reaction of hypersensitivity to 
the snake venom protein may appear.4 This is characterized by an egg-shaped 
erythematous swelling at the injection site which appears in from four to twelve 
hours and may last for as long as forty-eight hours. No general reactions have 









PECK AND GOLDBERGER: UTERINE BLEEDING 


889 


been noted. Wlien hypersensitivity occurs, it is advisable to reduce the concentration 
to 1:10000 with saline, but to continue the injections until a dose of 0.4 c.c. of 
1:3000 is used. By this means, desensitization without any untoward reactions was 
obtained in practically all of the eases where it was attempted. The injections 
should be planned as follows: 0.1 c.c. 1:10000, 0.4 c.c. 1:10000, 0.2 c.c. 1:6000, 
0.4 c.c. 1:6000, 0.1 c.c. 1:3000, and 0.4 c.c. 1:3000. 

CLINIOAl. DATA 

Twelve patients were treated with snake venom for functional uterine 
bleeding. The effect of venom therapy upon the regulation of excessive 
uterine bleeding is illustrated in five of tlie eases in Figs. 1, 2, 3, 4, 5. 



TWUTUSyr 


i»jBwc TtaATum 


AmR TRTATURrr 


Fig. 4. — Case 8, Table I. M. J., tw’enty-two years old. Married four years. Para i. 
Hgb. 26 per cent. Transfused 3 x. Curetted 4 x. 



Fig. 5. — Case 4, Table I. M. K., seventeen years old. Single. Hgb. 54 per cent. 
Curetted 2 x. 


The shortest period of time in which bleeding was controlled was in 
Case 8. This was a twelve-year-old girl who began to menstiniatc 
August, 1931. The first three periods were approximately normal in 
amount and duration, but since January 1, irregular profuse bleeding 
developed. The history and gynecologic findings were essentially- nega- 
tive. At the time treatment was instituted, she had been bleeding for 
several weeks. The fiist injection, 0.2 c.c. of the 1 ;3000 solution was 
given on April 20, 1932, a like amount was given on April 22, 1932, 
and bleeding ceased on April 24, 1932. There has been no recurrence 
of uterine bleeding up to the present observation, June 14, 1932. 

In most of the patients it rcciuired about six injections given over 
two to three WToks before any definite effect was noted. With the con- 



Table I 


890 


AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 


^3 

O 

(U 

^ o 


& 


d ^ 

■5 t-i 

c3 / 


bD 

d 

• fH 

a; 

o 


‘ a? » 


a> 


t- , 


2 W' 


O tH 

up o 

•4< CO 
T}H lO lO 


t* a 

(M • 


1^0 

, d d 

' a, I 

B g 

■« fl 


OQ 


fa 
o 5 

4^ O 
CQ ^ 


n3 

O) Q> 


MSwS 


^ © 

.2 ^ 

u . 

2 ^ 
P4 O 

.f^ 


i-i <M 
CO CO 


W CQ 
CO CO 


sCQ 


03 03 CO CQ • 
rH CQ To 
W wco IH 
CJ CO CO 'w's^ 
r~i r}< to 


r^J n3 n3 
O O O O 
C *C *?H *?H 
© © © © 
p4 P4 ft p4 

bb bb fcb bl) 

o © o © 

o t- 

CQ CQ CQ CO 


CQ CO O 

O O O O 


t}< CO CQ CO 
rH CQ CQ CQ 


CQ CO rjH lO 


'g'^rfrara 
^ ‘^ © © © 
*C ‘U © © C) 


ra n3 ^ 

o o 


, © © 

o o CQ CO rH 
— ' CQ CQ 


rH CQ CO CO ^ 
O O O O O O 

^ 4J 4J -♦-> 

CO CQ t> 03 CO lO 
r^ rH CQ 


rH (M CO CO W 


§ 2 

■= s 

CO 

© 


.CQ 
rt< CO 

O o 

'H 


.3 ^ 


O 


'. rjJ CQ 
© . F^ CO 

d © V. 

So 

> rH 


© 

It 

|o 


\CQ 
. CQ CO 
_^rH \ 

.ft 

a go 

© O 
ft . 
g-SrH 
1^^ ^CO 
O 


© 


.B^> 

CQ CQ 
O 

t- 

^ft CQ 
CO d d \ 

ft f-> ^ 

'.©'HO 

S ft . 

c5 d ^ _, 

13* 


• CO 


.S CQ CO 

^ \ 

§ ^rH CQ 
'-tdH ^ CO 
CO d d \ 

S o‘=» 

T H H CO 
'. © 'H \ 
© ft hJH 

© d 

H O 


d 

ft,2 

© © © M ftrv 

ia H t>a >-» 

2 £ £ d g g > 

3 ^ 3 © • « H 

poo f> MM *3 

UO 03 O O rH rH 
jCQ Cl CO CO CO CO 
03 03 03 03 03 03 


© © © 
bo bJD bXJ 
d d d 

•4^ 4.9 -M 
4^ 4.9 -H 
© © © 
H H H 

d d d 

ooa 

io rH rH 
ICO CO CO 
Io C3 03 


d 

© 

d 

© 

d © 

o 

H 

o 

© .rH 

H 

.2 H 

*CD 

d 

d 

bDg 

.2 'H 
ft CO 

d 

ro F.I 
d ^ 

CO 

O 

o 

't! O 
02 ^ 


3 .©©^ .©^ .© 

Eh d+30EH d+^H dn.* 


O rH 
CO CO 
O 03 


CO 

03 


© © 
bJO bJD 
d d 

4.9 4^ 
44 4.3 
© © 
H H 

d d 
OO 


00 00 CO 
Cl Cl CQ 
03 OS 03 


d . 


«• 


^ O o O >0 vO >5 
o o 

rH O O CQ O CO 

'O in o' o' 

CO CO i-( 

111 CO 


d R S 

WCcIPM^CLh^S 


^o o 
tf'O o . 


2 .S^ 

°-S- s s o 


y 53 O O v53 sS3 vS3 

ft O 03 Id rH 


' O O 
rH O 
l> CQ 


^ C O C 
Tf C © ft CO b- 
^ © O'ft"^ ^ 
OC ft 
CQ CQ 




o 


rt "2 

d © 


I rH 6 rCi . 

IdiaPMOMfil 


o 

br.PQ 


O 

m 


H P3 ^ d d B 


p 

tnfapuPCLiJ 


Cl ^ 
w « 

b. W 
o « 


bo 


be 


bb 


bxi 


Sib (U <u 
Ci rt !> -w 

<U .a -rH cj 

f^'p m a 


<u 

M « 


m © OT 
pd 
o 


“ s 2 2 

I » “ 

CO 


pH FH 


- ■ ■ 2 "H • 

■ M O g d 


I” bb 6 £?4S S 
I o S d ft d 

4J r ^ > d 

kH ^ ^ 

ft 03 fe <23 C 

j-.^ o ^ ^ o 

M bo 

loo !2 a d ^ . 

P O 3 ^ to 

” 'HOI-1 

CO 


bb g .§ '= 

2'^ ? O 

I'-' I Be 

d 


r of 00 

d ft 02 I 


i (M 


'H 


© fQ 

d . 


© d ►w 


oQ a 


ft . ft 
'P 15 3 g 


3 § - 

d ft © 


« a a 


iSs 

Cl 3 
^ © 


O 
H 

ft bX) 


HH CO d 

o © a 

“ a :n 

CO *^ — 

o 


03 


5 -H d g 
d d I-H d 


f>»T 


.CQ 


H 

©fS 

CO .2 
.02 


d 

© . 

d 

H 

d 

.P^ 

§ 


bD 

d 


- © 


-<Q 


M.-a 



Table I — Cont'd 


PECK AND GOLDBERGEK : UTERINE BLEEDING 


891 


03 M 

1 = 1 ' 

o c5 cO. 

O O 1 

Ph 02 I 



(M CO CO m 


6 u m <0 

I H ^ ^ ^ 

W eS C3 oi 

• 03 03 03 

'O 9f >03 tS 
o I-H o o o 

iO C5 C3 

^ W 
CO o lo o 
rt 


CO o »-H O r-i 
r-< CO CO CO 


CO CO CC »0 lO 


I-' 

bo . 

fi ^ 
.5 <M 

oj *s. 


03 

a 

CO 


03 ' 


O P 


p. o 2 

cq5^.- 

O O g CO 
CO rH P rH 
W \ 
CO lO 


(M 

CO 

Cq 

\ 

Tj^ 

03 

03 

.2 

*aj 

fcD 

P 

I 

n:? 

03 

03 

1-^ 

pP 

O 


B (M o 

^ CO 

o ^ 

o ^ c3 
CO P S 

^ s s 

’t S'” 

O fQ 
C3 P ^ 
rt > 

,o 


^ X Cvl 
B cq CO 

|o 

§ 


'S. 

w ^ 

1§S ” 

« • 


cq 

CO 


X \ 
cq o 
cq 

'v^cq 
. CO CO 


in' g 

. 0 > S-l 

O rQ 


Ico'^H S ’s 
I - g oo 

'H o 


C3 C5 

lo 


CO 

M 

o 

P -4^ 


'i'S ^ 
“ g'S'>a 

&CC 

Id 


P cq CO 
^ oq 
lo 

I 

|co rt 2 \ 
o 

03 f;0 -+0 

Icq-^ 


P 
03 3 

bp S 
P ^ 

03 

2 ^ 
^ rt 
C3 

oq 

O 


P P P 
0^0 0 
*Qa CO *m 
P P P 

«f-i tH ^ 
CO 03 Cfl 

^ P P P 
P P C c 3 

O H ^ ^ 
'm E-< ^ 

O O tH 
Cl CO CO 
O Ci C3 


CO 

P 

cS 

03 t-t 

bf-^ 

p 

cq 

03 


P 

*S 


lo t 2 

P w 
2 « 
S'rt 52 S 

a §■«£-< 


cq 

CO 

C3 


b£) 

s 

£ 

a 

O 

cq 

CO 

C3 


^.S .siS^# 

cq c c O ^ CO r-l 
PS x-T" 

o o 
M ;:^§ 


CO 


ro CO 


03 

a 


bD 


O 


O 


wS 6 ii^cut 4 


to-.- gw 


CO O O lO CO cq 

o 

CO 


d9 


yOOC-^v^vO vS® 

t>Of-i?POTtH mo 

- - -• -- COo“' 

o 
o 


^ d d^ 
o 

C3 


S § ^ CL g 'ii ^CL Jii 


o 

fc’rM 


o 
bhR 
W Pm 


w 

^ S 

fx X 

£ w 


bJD 

03 

t^; 


be 

03 


be 

03 

fc 


be 

03 

tz; 


O 03 CO 

a 2 P 

^ P p 
<H P 

g'^3 

P4 


be . 

03 p ■** 

p (•% p 

- - P ^ o 

X M 03 03 


03 


l<^ 

I .S S I o 

,^CQ O^ P 
iO . 

I X . O ?P 
CO o OT d 

cq be a o o 

X P ^ w -M 
cq 


p CO 
I CO 03 0) 




03 03 — 

l> 3 1 g 

, X cq CO 
CO ^ 
CvJ «H P 

' X o 'P 


r-X w 


be 
p tOp 


• O 03 •*■> «J 
4-i ^ 

n c C3 

p-.i: c 03 
tM (M ti 

<5«gg g 

r-1 r-l »«-i 

c« a a -g 

bf ® i5 12 ° 

g-r-l l-j t-3 u 

PP 


01 

%, 

g 

!» 


o 

03 

03 

'be 

I'bJD 

I’tX) 

p 

1 C 

1 p 


m 

;w 




'4< 


o.-^ 

<j^ 

in 


o g 

r6 


Pl-3 

oa^ 


«.-§ 



892 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


/-N 

d 

(M 3 w 5 

CO p^co Ph 

O P C5 p 
(M pH 


P^ b 

S'?! ° 

m ^ 

“I I 

s^\ ^ 

w o o 

CO 4J 05 
'*N» CO 

CP t- t> 5 
Cq 1-1 «H 


I CQ 

rp p\ 

: s §2 

< ^ r-I 
• O 'H \ 
> 1^ ^ Ip 

o 

. H-) (> 4-3 


CO rt P \ 

s 

'« S ^ o 

O ra -M 

c3 CJ ^ 

^ ^ x2 
[ *+J »»" CO 

o 


N 

IP 

ci^ rt S \ 
:: B 2^ 
S'H o 

O rn 4^ 
P P Jd <-■, 

P C<J 
^ 4J ? CO 


o _>o 
o ^ \ 

co''^ 

••so 

5 CH o 

o n3 

o s ^ 

fc. eg 


- oa CP cq 
rco r-l 


o o o 

rt<Oipi>.CCIr 4 000Nl:-. 
CO ^*"^0 CO t- rH : 


0)0 0? 
b£) bJD bjD 

S rt S 

4-3 4-3 4-) 
4-3-4-3 4-3 

O 0) 0) 
^ P Im 

S P s 
Qoa 

O M r- 
CO CO CO 
O) c? o? 

1— ' r-4 t— I 


• o o o ' 
o ^ 

IP M 


w vy 

! sf q d 9 

:CLiiJia^ dfL^FUdWtfd^FMi-i 




o 

,« CO 

CO ^ 

^ O , 

03 

4-330 


m r 3 TO 
TO ^ 05 2 

03 S 

•2'=>3 

P 0) P 

^<0 s« I 

M . fee P( 

s.a5.s^ 

PU 


'S e<j 
^ rP 

-S 0) d 

O TO S 

p o .2 

0 ) d 4 J 


£ O 0 ) B 

M Si ^ 3 
0 ) 4-3 LJ © 
S 05 ^ 43 

;3 cp p 

i 

^ o' 6 S 
0.2 .2 ' 


2 ^ o s-T"^ 

^ fcJD CJ 

rt ^ 

X 2 qT'- 

i 3 |g s g « 

J< 'HOP 

CO 


3 

<5 

Ah 

Married 

Single 

Married 

Married 
Para, i 


iH 

CO 

CO 

0 

< 


r4 

CO 

CO 


. 0 

. 0 

. © 

»-5 S 

s 

n.-s 

K 

0.-5 

hW 

< 


02 ^ 

c4^ 

si 


C5 

0 

r4 

ci 




1-4 

iH 


nnuous ± 0 r Macrocysts then lx wk. to 

entire month in both 3/17/32 3 x wk. 

ovaries from 3/17/32 to 

3/25/32 



PECK AND GOLDBERGER; UTERINE BLEEDING 


893 


trol of the -uterine bleeding, there was a rapid improvement of the 
secondaiy anemia usually present. Ten of the cases responded well. 
In one, the final result was poor (Case 12). 

This patient, a thirty-year-old married woman, gave a history of irregular and 
profuse uterine bleeding for three years. The gynecologic findings were adherent 
retroflexed uterus and bilateral maeroeystic ovaries. She had had three curettages 
with only temporary relief. Venom treatment was begun Jan. 30, 1932, during a 
period of profuse bleeding wliich had lasted over a week. The injections were 
continued twice a week, the average dose being 0.4 c.c. of the 1:3,000 solution. 
After four injections given in ten days, the bleeding stopped. The injections 
were then continued at rveekly intervals until March 17. Bleeding began again 
on February 27 and lasted for six days; scant bleeding for the first tliree days 
and moderate bleeding for the last three days. On March 17 she started to spot 
and from March 19 to the twenty-fifth there was a heavy flow'. During this 
bleeding period, she received three injections of venom. After an injection on 
March 22, the bleeding diminished very much and on March 25 it stopped. She 
then became sensitized to the venom protein so that the dosage had to be markedly 
reduced. Bleeding began again April 29 and lasted nine days, moderate flow. 
She was then desensitized with further injections of venom and from May 24 to 
June 3 she received four injections of 0.4 c.c. 1:3,000 solution. She began to 
spot on May 19 and tiien bled actively until the last observation June 7. In 
view of the fact that she was bleeding very profusely, in spite of the long course 
of venom injections, it was decided to discontinue treatment with venom. She 
was operated upon for lier retroflexion of the uterus and bilateral niacrocystic 
ovaries. Subsequently patient died. Autopsy show'ed a peculiar type of generalized 
Hodgkin’s disease. 


In Case 5, Fig. 3, the result was only fair, although the uterine bleed- 
ing was controlled. There tvere five menstrual periods of three to seven 
haj's’ duration from February to May. Fi’om Maj'’ 24 to June 7, 1932, 
there was a scant flow for five days, moderate for three days and pro- 
fuse for the last six days. Because of this long period, this case will 
require further treatment and obseiwation before it can be accepted 
as markedly improved. 

SUMMARY 


The therapeutic effect of moccasin venom (Ancistrodon piseivorus) on 
twelve cases of functional uterine bleeding is presented. The period 
of observation is too short to draw any final conclusions about the 
permanence of the results. The therapeutic effects obtained are satis- 
factory enough to warrant the clinical trial of venom therapy in eases 
of this type. 


REFERENCES 


Samuel M., and SohotM, Earry E.: J. Exper. Med. 54: 407, 1931. 
U) Pcch, Samuel M.: Proc. Soe. E.xper. Biol. & Med. 29; 579, 1932. fS) Franl; 
Pohcrt T.: An. J. Obst. & Gynec. 24; 574, 1932. (4) ^ Peck, Samuel M - 

Arch. Derm. fcSyph. 27; 312,1933. 


125 East 72nd Street. 
143 IYest S6th Street. 



ABRUPTIO PLACENTAE 
ISADORE A. SlEGEIi, A.B., M.D., BALTIMORE, Md. 

(From the Obstetrical Department University of Maryland Medical School) 

aBRUPTIO placentae, ablatio placentae, and premature separation 
/x of tlie placenta are terms which are used to describe one and the 
same condition; namely, the premature separation of the normally im- 
planted placenta, which generally occurs in the latter months of preg- 
iiancj^ or during labor. It is this clinical entity which I wish to con- 
sider after analyzing the cases as they occurred in the University Hos- 
pital of the University of IMaryland ]\Iedical School. 

We report here 62 cases of abruptio placentae which were treated 
in the University Hospital from 1923 to 1931 inclusive. During this 
period of time we delivered approximately 3000 patients. These cases 
include all degrees of separation from the mildest with visible hemor- 
rhage occurring late in labor to the severe type of complete separation 
with concealed hemorrhage and one ease of placental apoplexy or the 
so-called Couvelaire uterus. This gives us an incidence of 1 in 48.39 
cases. The incidence reported by others varies from 1-200 to 1-400 
cases. Our series and incidence, therefore, is quite unusual. In order 
to make this high incidence understandable, it is necessary to laiow that 
the University Hospital has a limited number of maternity beds; that 
it serves as an outlet for the pathologic cases from our own Out-Patient 
Department where we deliver from 1200 to 1500 patients annually. 
That we receive practically all the abnormal cases from the City Ob- 
stetrical Service and that we likervise receive many of the pathologic 
cases from the city and state physicians. In other words, our beds of 
necessity are restricted to abnormal and pathologic cases. This conse- 
quently increases our incidence in all our pathologic cases; therefore, 
we do not represent the more true incidence of abruptio placentae as it 
occurs in hospitals having a more nonnal population. 

Premature separation of the normally implanted placenta occurred 
in 35 white and in 27 negro patients, sho-vving a slightly higher incidence 
in the white patients. 

There were 5 cases occurring between the ages of fifteen and nine- 
teen; 26 between twenty and twenty-nine; 31 between thirty and forty 
5 ’'ears. The age of the youngest was fifteen and the oldest forty jeavs. 
The condition in our series occurred most frequently during the active 
period of reproduction. 

There were 10 cases in the primiparas and 52 in the multiparas, in- 
dicating that abruptio placentae is most prevalent in the multiparous 
but is not uncommon in the primiparous woman. 

894 



SIEGKL ; 


ABKUPTIO PLACENTAE 


895 


Sis cases occurred between fourteen and twenty-nine weeks’ gestation; 
25 between twenty -nine and thirty-seven weeks; 31 between tliirty-eight 
and forty weeks. The case of fourteen weeks was one of twins. These 
figures seem to indicate that premature separation of the placenta is 
apt to occur most frequently after the period of viability. 

There were 49 cephalic presentations, 7 podalic, 1 transverse, and in 
5 the presentation was not noted. 

In attempting to analyze the possible etiologic factors in these cases, 
we found that 37 patients showed no abnormalities and 8 patients 
showed only a trace to 1-plus albumin in the urine. Three eases oc- 
curred in preeelampsia, 1 ease in eclampsia, 1 case in undetermined 
toxemia, 1 ease in pulmonary tuberculosis, and 1 ease in possible trauma; 
2 patients had only hypertensioai, 7 patients had nephritis, and 3 patients 
had syphilis. 

In the 45 cases that showed no real pathology, 16 patients had only 
slight bleeding, 11 moderate, and 19 profuse bleeding. In the entire 
series, however, 24 patients had slight bleeding, 17 moderate, and 21 
profuse bleeding. 

Our treatment of these patients was varied. Twenty-one patients 
were permitted to deliver themselves spontaneously; 5 had the mem- 
branes ruptured artificially with spontaneous delivery; 2 patients were 
bagged and allowed to deliver spontaneously. There were 8 forceps 
deliveries; 8 versions and breech extractions; 4 cases of breech extrac- 
tions; 1 case bagged and delivered by breech extraction. There were 
10 patients delivered by classical section and 1 patient by laparo- 
ti'achelotoray. 

The supportive treatment in these cases consisted of 10 per cent glucose 
intravenously in 2 cases, saline and glucose intravenously in 6 cases, 
and saline infusion alone in 14 eases. Two patients received preopera- 
tive blood transfusions, 3 patients, postoperative blood transfusions. 
In onlj*- 2 cases was it found necessary to pack the uterus. 

There were 6 maternal deaths (9.68 per cent). This is an uncorrected 
mortality. One patient died of peritonitis, 1 of miliary tuberculosis, 
and 1 of ruptured uterus. There were 2 cases of hemoimhage and 
shock, and 1 ease of postoperative pneumonia. The follomng are brief 
abstracts of the eases terminating fatally. 

Case 1. — No. 41582. C. lU., negro, aged twenty-four, para v, admitted Dec. 31, 
1924, with a history of pain in abdomen for twenty-four hours. She said she hurt 
berself carrying a basket of clotlies on Dec. 29, 1924, and on the following day at- 
0:00 A.M. she began to have pains. Examination showed uterus tense and rigid 
•ind extending to ensiform cartilage. Fetus could not be outlined nor fetal heart 
beard. She was given continuous saline infusion, cervix was manually dilated and 
version with breech extraction performed delivering a Iwenty-eight-week stillborn 
fetus, followed immediately by the free placenta and many old blood clots. The 
uterus contracted down well and no more bleeding occurred. Patient was shocked 



896 


AjMERICAN journal op obstetrics and gynecology 


and despite all stimulation died seven hours postpartum. This case illustrates the 
great danger of dilating the cervix by accouchment force. 

Case 2. — No. 42526. F. C., negro, aged thirty-four, para v, was admitted on 
March 14, 1925, after having been in labor for twenty-four liours, with the uterus in 
a state of tetanic contraction and with slight vaginal bleeding. Fetus could not 
be outlined nor fetal heart heard. The pulse was 120, and temperature 99.6°. 
Saline infusion given. Vaginal examination showed cervix to be fully dilated and 
head floating. In attempting to do a craniotomy the head slipped away and the 
feet could be felt so that an easy version and breech extraction was done. The 
placenta was lying free in the uterine cavity from which it was removed with many 
old blood clots. One hour after delivery the patient’s condition was grave but she 
improved under stimulates and infusions. She vomited and upon gastric lavage a 
large quantity of black tariy fluid was obtained. The next day she had a 
hematemesis and passed blood per rectum. Horse serum and other symptomatic 
treatment failed and she died on the third day. Autopsy showed gangrenous 
endometritis with perforation of the lower anterior wall of the uterus, hemorrhage 
in the peritoneal cavity, acute generalized peritonitis, acute diphtheritic inflamma- 
tion of the esophagus and stomach, acute entereolitis and acute nephritis. It is 
quite possible that the operator in the attempt to perforate the fetal head may have 
perforated the anterior uterine wall without having been aware of it. 

Case 3. — No. 49685. H. Me., aged thirty-two, white, para iii, was admitted 
Aug. 26, 1926, with history of bleeding, beginning at 6:00 a.m. and with slight 
abdominal pain. The pain and bleeding gradually increased and the uterus be- 
came more and more rigid. At 12:00 noon when she arrived at the hospital, lier 
pulse was 144, uterus rigid and tender, fetus could not be outlined and duration 
of pregnancy was thirty-six weeks. The cervix was 3 fingers dilated. She was 
given saline infusion, the cervix was inanualty dilated and a stillborn fetus was 
delivered by breech extraction. Placenta and many old blood clots were removed. 
The patient was shocked and failed to rally, dying at 2:00 P.M. This is another case 
showing the danger of accouchement force. 

Case 4. — ^No. 55651. L. S., aged twenty-one, white, para i, admitted Oct. 23, 
1927, with history of having bled one month ago and began to bleed profusely 
today. She was examined at home vaginally by midwife and doctor. This was 
learned after the patient was operated upon. Her pulse was 96, temperature 98.6°, 
blood pressure 122/70, R.B.C. 2,900,000, Hb. 38 per cent, abdomen tense and tender, 
fetal heart not heard, cervix closed. She was given a blood transfusion of 500 c.c. 
and delivered by laparotrachelotomy. A large amount of serosanguineous fluid was 
found in the abdominal cavity. Tlie placenta was lying free in the uterine carity 
which contained much blood. During the operation the patient received 700 c.c. 
saline by infusion. Postoperative her pulse was 102, temperature 99°, blood pres- 
sure 88/54. She received 2 postoperative blood transfusions of 500 c.c. and 300 cA. 
respectively. She ran a stormy course and died fourteen days postoperative of 
generalized peritonitis. 

Case 5. — ^No. 56007. B. H., aged thirty-two, negro, para vi, admitted Nov. 24, 
1927, because of tense and tender abdomen with external bleeding. On November 
22 she had slight pain in her abdomen which became worse the next day with some 
bleeding. The uterus was the size of thirty-eight weeks’ gestation, very tender, 
hard and firm, R.B.C. 2,000,000, Hb. 33 per cent, pulse rose from 84 to 118, blood 
pressure 118/60, cervix 1 finger dilated. She was given morphia, saline infusion 
and 600 c.c. of glucose intravenously and delivered by classical section. The 
uterus was dark blue and mottled. A thirty-six-week stillborn fetus was delivered 



REEVES; RETZIUS SPACE ABSCESS 


897 


and many blood clots found in tlie utenis. The uterus contracted on stimulation. 
The blood pressure dropped to 78/46 but rose the next day to 110/60. Porty-eight 
hours postpartum she developed pneumonia and died Nov. 26, 1927. This case 
perhaps may fall in the class of the Couvelaire uterus. 

Case 6.— No. 60067. L. J., aged thirty-three, white, para viii, was admitted 
TOth history of having bled six weeks ago and began to bleed again. She was 
about twenty-two weeks’ pregnant, very pale, and emaciated. Lung examination 
showed miliary tuberculosis. Patient ran a typical septic course, placenta previa 
was ruled out but she continued to bleed, and it was deemed advisable to interrupt 
lier pregnancy. On the tenth day in the hospital, her cervix was packed and she 
delivered herself the next day without any difficulty. Her condition became rapidly 
worse, and she died on the seventh day postpartum of diffuse miliary tuberculosis. 

Fetal mortality; There were 36 fetal deaths (57.1 per cent). Of 
this number 16 were premature stillboni including one pair of twins, 
16 full-term stillborn babies and 5 premature bom alive but which died 
before leaving the hospital. There tvere 7 premature and 19 full-term 
living babies discharged from the hospital. 

Morbidity; There were 21 cases showing a morbidity. Among this 
number was 1 case of wound infection, 1 of phlebitis, 1 of broncho- 
pneumonia, 1 of pyelitis, and 1 of puerperal psychosis. 

2309 Eut.\w Peace 


RETZIUS SPACE ABSCESS FOLLOWING LAPAROTOMY? 

E. Edwin Beeves, M.D., Amarillo, Texas 

CUPPURATION in the area designated by Retzius as “the space 
in front of the bladder” is infrequent, and exceedingly rare fol- 
lowing simple laparotomy. This prevesical space received the name 
cavum Betzii, since Retzius gave its clinical applications in a paper 
before the Academy of Stockholm in 1856. In reality, there is no 
cavity present, but the space is occupied by loose areolar and adipose 
tissue. 

A review of the literature reveals comiiaratively few articles deal- 
ing with the Retzius space abscess, and the genitourinary surgeons 
have written more extensively than others upon the subject. Goldstein 
and Abeshouse conclude that prevesical infection frequently occurs as 
a complication of suprapubic cystotomy and results from flooding the 
operative field with septic urine. In earlier reports we find that Budin 
described a case in a child of thirteen days of age that came to autopsy, 
and in which he demonstrated streptococci as the causative factor. Mar- 
ten operated upon a child sixteen months of age with excellent results, 
this being the fii-st operation for prevesical abscess in a patient less 
than ri ght yeai-s of age. Michels reported four cases of prevesical ab- 

Uf'.Tfl before the Amnrillo Acaflemy of McRictnc. Marcli 29. 1932. 



898 


AjMERICAN journal op obstetrics and gtnecologt 


scess in 1895, giving the etiologic factors, diagnostic methods, and treat- 
ment. Little change could be made at the present time of the facts ho 
stressed in his paper. In 1903 P. Targhetta rendered an extensive re- 
port of a case in a male four j^ears of age, -which developed after a kick 
in the abdomen. He confirmed the diagnosis by exploratoiy supra- 
pubic puncture, following which he performed an operation by vertical 
suprapubic incision with successful results. The culture was pure 
streptococcus, and Targhetta concluded that the infection came from 
a lesion in the bladder mucosa, by waj"- of blood or Ijmipli stream. The 
lesion resulted from the injury, whereas, the bacteria came from the 
urine. Chatillon, at a later date, gives a somewhat similar explanation 
of infection spreading by the hematogenous route. His was the case 
of a young woman, who in early puerperium, developed bronchopneu- 
monia, which was in turn followed by prevesical abscess. The cough- 
ing was the exciting factor in producing bronchial lesions, thereby al- 
lowing infection to gain the blood stream. However, in his case the 
pus from the abscess was sterile. Nevertheless, this author cites the 
case of Kummer in which the Eetzius space abscess followed pneumonia, 
and pneumococci were found in cultures from the abscess, klention 
should be made of the case reported by Brun, Avhich was of appendic- 
ular origin and at a later stage ruptured into the -bladder. Lilcewise, 
the case of Kuhn, which was of traumatic origin, is interesting. 

In this presentation, an attempt Avill be made to demonstrate an un- 
usual complication of laparotomy for pelvic disease of women, and to 
stud}’- the anatomical relationship, causative factors, and prevention. 

The prevesical space of Retzius lies above the pubovesical ligament; 
its lower anterior lioundaiy consists of the symphysis pubis and the 
side walls of the pelvis; the upper anterior boundary is the trans- 
versalis fascia; the posterior boundaiy consists of the anterior border 
and the inferolateral surfaces of the bladder, with also the lateral false 
ligaments which stretch from each lateral superior surface of the bladdei 
to attach to the side walls of the pelvis. The upper limit is marked 
by the anterior peritoneal reflection together with the urachus, which 
extends from the apex of the bladder to the umbilicus; but Graves 
describes also a thin membranous fascia called the umbilicovesicalis 
fascia, which comes from the pelvic floor and passes over the bladder 
to the abdominal wall and fuses with the transversalis fascia. Some 
authors describe this fascia as being attached at the semilunar fold of 
Douglas. The space contains the anterior and lateral Ij'^mph glands of 
the bladder and portions of the hj^iogastric group in relation to the 
h5'pogasti’ic arteries. The last named group has connections mth the 
parauterine and anorectal glands. 

By keeping in mind the above mentioned anatomical features, and 
remembering the fact that the presvesieal space is entirely extraperi- 



RHEVES : 


HETEIUS SPACE ABSCESS 


899 


toneal, we can more readily comprehend the ease herewith reported and 
the operative technic used. 

CASE REPORT 

Miss X., clerk, aged eigliteen, reported for office examination on Sept. 24, 1931, 
complaining of vaginal discharge, lassitude, occasional feverish and chilly sensations, 
lower abdominal discomfort, backache, and occipital headache. The infection was 
contracted six months previously following sexual exposure, and she had experienced 
mild acute upsets at varying intervals. The discharge was of creamy yellowish 
type, and there was some accompanying vesical irritation. 

Her menses began at the age of twelve years and were normal until the onset of 
present illness, when she developed backache and occasional clots. 

The family history was negative; her past history revealed marked constipation 
for the past two years, and pleurisy in 1929. The general physical examination was 
negative, except for hypertrophied tonsils and the abdominal and pelvic findings. 
There were no palpable masses in the abdomen, however, tuboovarian tenderness was 
present. The vagina was congested and contained a mucopurulent discharge; the 
uterus was slightly retroverted; both tubes were enlarged and moderately tender; 
the cervix w’as eroded. The urine was negative; the W.B.C. count w'as 10,400; the 
R.B.O. count 4,250,000; and the cervical and urethral smears revealed gram-negative 
intracellular diplococci. 

She was given expectant treatment for a few days, but was admitted to 
St. Anthony's Hospital on October 2. She was operated upon the following day 
under spinal anesthesia of 200 mg. novocaine. The operation consisted of cervical 
cauterization, bilateral salpingectomy, right oophorectomy, and appendectomy; also 
the round ligaments were shortened somewhat to pj-ovide adequate uterine support. 
The pathologic report revealed chronic bilateral pseudofollicular salpingitis; small 
cystic follicular atresia of the ovary; and chronic appendicitis. 

The immediate postoperative recovery was excellent, however, there was an early 
rise in temperature and a somew'hat atypical septic chart continued after the second 
postoperative day. She had some nausea and vomiting and a fair amount of 
abdominal distension, though she retained a reasonable amount of nourishment, and 
physical depletion was not rapid. At times she had slight pain in the lower abdomen, 
but there was no infection of the incision. There was considerable restlessness and 
mild delirium on October 9, when the temperature arose to 104.2° F. A malarial 
smear made at the time was negative. Even though a careful abdominal and 
vaginal examination was made, I was unable to determine the nature of the 
complication. There was a slight improvement followung this, but the temperature 
peaked again on October 13, reaching 103.4° F. This follow'ed a second vaginal 
examination which w'as made on the previous day, and in which I was again 
unable to make a diagnosis. At this examination, eight ounces of residual urine 
was removed by catheter, this being the only instance of urinary dysfunction during 
the entire illness. 

On the morning of October 14 (the eleventh postoperative day), a third abdomino- 
vaginal examination revealed definite evidence of fluctuation behind the symiphysis, 
also slight fulness of the iliac regions. Nevertheless, the patient did not experience 
any significant pain during the examination. A diagnosis of Retzius space abscess 
■was made and was confirmed by Dr. W. Forest Dutton. Consequently, that afternoon 
the abscess cavity was opened by a vertical suprapubic incision close to the 
sjnnphysis, under nitrous oxide anesthesia. The abscess cavity was immediately in 
front of the bladder, and, laterally, it occupied both paravesical fossae. It evidently 
contained about 250 c.c. of the dark brown pus, however, no aspiration was done. 

10 pus had the characteristic odor of colon bacillus infection. The abscess cavity 



900 


AJilERICAN JOURNAL/ OP OBSTETRICS AND GYNECOLOGY 


was entirely extraperitoneal, and the upper limit of extension was only about 3 cm. 
above the symphysis, thereby, confirming Graves’ contention of fascial relationship. 

It is well to explain the secondary operation in more detail. The suprapubic 
incision was made at the extreme lower end of the initial incision. The lower fascia 
was found firmly united, and a scalpel was used in opening the abscessed cavity. 
Above, however, the recti fascia had separated its entire length. There was no pus 
in the original incision, but tliere was a small thread-like clot between the recti 
bellies of the upper half of the incision. I am inclined to believe that this clot 
resulted from my injudicious probing a few days prior to operation. The peritoneum 
was intact throughout. Closure was accomplished by interrupted chromic catgut to 
fascia, silkworm gut stay sutures, and dermal to skin. A Penrose drain was placed 
in each paravesical fossa, and a tube drain was inserted between these and in 
front of the bladder. 

Immediate improvement took place, and convalescence was uneventful, except for 
slow healing of the drainage wound. (The blood Wassermann was negative). 



Pig. 1. — Showing Retzius space abscess and method of diagnosis: a definite fluid 
wave after catheterization, distorted bladder and displaced uteru.s. 

On November 9, under one per cent novocaine anesthesia, three silkworm gut stay 
sutures were placed so as to hasten repair of the drainage wound. 

Just before operation the W.B.C. count was 21,400; E.B.C. count 3,500,000; 
hemoglobin 75 per cent; polymorphonuclears S3 per cent. Several other counts were 
made postoperative and revealed a continued reduction of leucocytes and poly- 
niorphonuclears. The anemia was rather marked and was combated with intravenous 
iron and arsenic, tonics, and liver diet. A month after operation, the "W.B.C. count 
was 9,150; E.B.C. count 3,820,000; hemoglobin 75 per cent; polymorphonuclears 
62 per cent. 

A vaginal examination on November 18 (five weeks after the secondary opera- 
tion) revealed the uterus in normal position and freely movable. There was no 
tenderness in the lateral fornices and no cervical erosion. The patient left the 
hospital in good condition on November 20, and continued to gain weight and 
strength. When examined on Jan. 23, 1932, she weighed 122 pounds, which was 
very satisfactory inasmuch as her weight when she regained the chair on November 
3 was 105 pounds, and her former normal weight was 120 pounds. The abdomen 
revealed marked cicatrization, but there was good recti function and no diastasis. 



REEVES: RETZIUS SPACE ABSCESS 


901 


Catheterized urine specimens indicated the presence of a low grade pyelitis, which 
developed after the initial operation, but began to subside after the secondary 
operation. This feature made the diagnosis of the complication more difficult. 

DISCUSSION 

The etiology of the secondary infection is debatable, however, it is 
likely that it was of colon bacillus type, and was probably spread by 
lymphatics. Since colon bacilli are frequently present in the vagina 
and cervix, the cervical cauterization may have stimulated an extension 
to the parauterine nodes. Also, due to prolonged constipation and stasis, 
it is possible that the anorectal nodes maj' have become infected at a 
time of lowered resistance. The urine may have contained colon bacilli 
and infection could have easily been transmitted to the anterior and 
lateral lymph glands of the space of Eetzius. Even though care was 
exercised, it is quite possible that a small bleeder was overlooked, and 
there may have been a collection of blood in the prevesical space, there- 
by supplying an excellent media for bacterial growth. In my eagerness 
for good pelvic exposure, it is probable that the incision went beyond 
the apex of the bladder, and in front of it, thereby exposing the space 
of Eetzius. This would explain the possibility of a hematoma occurring 
in the prevesical space. 

CONCLUSIONS 

1. Statistics reveal that Eetzius space abscess occurs most frequently 
in the young. 

2. It is most frequent after certain bladder operations, but is rare 
following a gynecologic laparotomy. 

3. The almost complete absence of vesical symptoms in this case is 
striking. 

4. Early diagnosis is difficult. 

5. Care should be exercised in making incisions so as to avoid enter- 
ing the prevesical space, and a more careful search for, and tying of, 
bleeding vessels should be done. 

6. Drainage of suspicious cases is important. This case, however, 
appeared sufficiently clean, and intraperitoneal drainage would have 
been of no value. 

7 . Cultures should be made to determine the exact nature of the 
infection; therefore, the author offer’s apologies for neglecting this 
leature in the case just reported. 


REFERENCES 

(1) 2?ni;i, F.; Presse nied. p. 341, 1S96. (2) Chatillon, Fermud: La Gyne- 
cologic, ICo p Cunningham, D. J.: Cunningliam’s Manual of Practical 

Anatomy, 1918, Wm. Wood & Co., pp. 619-633. (4) Cunningham, D. J.: Text Book 



902 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


of Anatomy, 1916, Wni. Wood & Co., pp. 4S9-493; 1015-1018. (5) Curtis, A. E.: 

Text Book on Gjmecology, 1930, W. B. Saunders Company, pp. 40-42. (6) Gold- 
stein and Aieshouse ; Surg. Gyuec. Obst. 41: 477-501. (7) Graves, E. C.: Practice 

of Surgery, Dean Lewis, 1928, W. F. Prior Co., Inc. 8: 11. (8) Kuhn, C. F.: Am. J. 

Dermat. & Genito-Urin. Dis. 15: 312, 1911. (9) Michels, Ernst; Proc. Eoy. Med. & 
Cliir. Soc. 8: 97, 1895-96. (10) Werner: Hand Atlas of Human Anatomy, J. B. 

Lippincott Co., p. 621. (11) Targhetta, P.: Clin. Cliir. Milano 12: 744, 1904. 

605 Oliver-Eakle Building 


ADENOMYOMA (ADENOMYOSIS OP PRANKL) OP THE 
UTERUS AVITH TUBERCULOUS INPECTION 
R. H. Rigdon, M.D., Durham, N. C. 

(From the Department of Pathology, Dulce University School of Medicine) 

T he frequency of adeuonij^oma of the uterus is evident from Cul- 
len’s study of 1283 myomas- in which he found an incidence of 
5.7 per cent. 

Tuberculosis of various portions of the female genital tract is by 
no means a rarity. According to AArilliaias® the order in which the 
various pelvic organs are involved is as follows : tubes, uterus, ovaries, 
vagina, cervix, and vulva. On the other hand tuberculosis limited to 
the mj'-ometrium is very rare. In a series of 200 cases of tuberculous 
salpingitis, Greenberg'* found the myometrium involved alone in only 
four eases. It is evident from this that the combination of adeno- 
myoma and tuberculosis would indeed be a rarity. 

Von Recklingliausens in 1896 reported the first two cases of adenomyoma of the 
uterus with tuberculous infection. The first occurred in a woman forty-four years 
old, who was sterile. The patient had dysmenorrhea all her life and during the 
four years previous to operation became severely anemic due to hypermenorrhea. 
The tumor removed at operation was somewhat smaller than a fetal head and on 
microscopic examination it showed dilated gland-like spaces and tubercles spread 
throughout the entire uterine wall. One portion of tlie tumor showed an adeno- 
carcinoma in addition to tlie adenomyoma and tuberculosis. The second ease was 
that of a woman fifty-five j'ears of age who was also sterile. This patient reached 
her menopause at thirty and during the ten years previous to operation she had 
irregular intervals of bleeding. The tumor removed at operation was approximately 
the size of a closed fist and on histologic examination showed a carcinoma of the 
endometrium and an adenomyoma with a tuberculous infection. 

Von Recklinghausen at first ascribed the origin of adenomyomas to the re- 
mains of the wolfSan body; however, he later reported one case in which the 
glands in the myoma evidently grew from the glands in the endometrium and lie 
therefore reached the conclusion that although most adenomyoma arise from the 
remains of the wolfiian body others have their origin from the uterine mucosa. 

Since von Recklinghausen’s monograph the occurrence of the combination of 
tuberculosis and adenomyoma has proved to be rare. Johnstone,^ in 1924, found 
only 6 cases in the literature and to tliis he added another. To these should be 



EIGDON : ADENOMYOMA 


903 


added the cases of Dieksonf and Gage,® making a total of 9 cases reported to date. 

Moench,® in 1923, reviewed the literature in a study of "Tuberculous Ovarian 
Cyst” and was able to find only 33 authentic cases. The majority of these cases 
occurred in intraligamentous and dermoid cysts. Likewise rare is the combination 
of tuberculosis with or in ovarian tumors. 

Eecently we have had the opportunity to study a case illustrating both these 
rare conditions, namely, adenomyoma of the uterus and eystadenoma of the ovary', 
both accompanied by tuberculosis. 


CASE REPORT 

Our case occurred in a white female forty-nine years of age whose chief com- 
plaint was irregular menses. Menstruation began at the age of seventeen and each 



— Adenomyoma of the uterus ; a. Intramural flbromyoma. b, endometrial 
mvn.' ^^®cous material, tuberculous, in the adenomyomatous areas ; A, cystadeno- 
"‘joma of the ovary filled with a caseous material. 


period was associated with moderate pain. The patient was married but never 
pregnant. She had had two previous operations, one for a gangrenous appendix 
5ibd one for a hernia. There was nothing in the past history' or in the physical 
examination to suggest a tuberculous infection. 

Since the onset of the present illness, one year previously, the patient had failed 
to menstruate one to two months in succession while at other times she had bled 
for fourteen or fifteen days. There had been a white vaginal discharge with some 
pain in the lower abdominal quadrants for one year. 

On admission the temperature was 98.6“ F., pulse 90, respiration 20, blood pressure 

-0/SO, white blood cell count 9,300. The urine was negative except for a trace of 
albumin. 




904 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


At operation there were encountered onlj' a few adhesions and in the fundus of 
the uterus a tumor approximately the size of a cocoanut, wliich resembled a 
fibromyoma. The left ovary was cystic and contained a thick creamy material, 
smear and cultures from which showed no organisms. The right ovary was small 
and atrophic. 

The uterus with 2 to 3 cm. of both tubes and the cyst of the left ovary were 
removed. The patient made an uneventful recovery and was discharged fifteen days 
after operation. 

Gross Fathologio Examination . — The uterus measured 12 cm. from the cervix to 
the fundus and 11 cm. in its transverse diameter. The portion of ceiwix measured 
1.5 cm. The uterus, except for some irregularities and a few fibrous adhesions, 
was relatively smooth. IVlien the organ was sectioned in the anteroposterior plane, 
the uterine cavity was found to measure 6 cm. in length and at the internal os 
it had a diameter of 6 mm. whieh decreased in size as it approaclied the fundus. 
Surrounding the uterine cavitj- was a margin of spongy tissue 2 mm. in thickness. 
The cavity was compressed in its posterior part by a circumscribed, well-outlined 



Pig. 2. — Photomicrograph of one of the adenomyomatous areas in the uterus showing 

the tuberculous infection. 

tumor mass which produced a disproportion between tlie anterior and posterior 
halves, the former having a thickness of 5.5 cm., while the latter measured onlj' 
4 cm. This tumor, which measured 3.5 cm. by 2.5 cm., was composed of whorls of 
white fibrous tissue between some of which could be seen what appeared to be 
dilated blood vessels. The remaining cut surface of the uterus was composed of 
bands of white fibrous tissue of various sizes which passed in many directions. 
Between these bands of fibrous tissue were numerous irregularly shaped areas of 
caseous material. There were occasional cavities between groups of muscle fibers. 
At one point there was a small cyst, 5 to 6 mm. in diameter, which closely ap- 
proaclied but apparently did not communicate with tiie uterine cavity. This cyst 
resembled somewhat a miniature uterine cavity. 

The tubes were about 1 cm. in diameter, and on the surface showed a few 
fibrous adhesions. 

Tlie ovarian cyst was moderately soft in consistency and measured 4 cm. in 
its greatest diameter. The external surface was slightly irregular in contour due 
to a few fibrous adliesions. On section, the cyst was filled with a caseous material. 




RIQDON : ADENOMYOMA 


905 


The wall varied from 1 to 5 mm. in, tliickness and showed dilated channels which 
resembled blood vessels. 

Histologic Examination . — The diffuse enlargement of the uterus was due to 
fibromyomatous bundles of varying size. Throughout the section between the 
bundles of muscles one found gland-like structures of various sizes lined by columnar 
epithelium and surrounded by oval shaped cells resembling those found in the 
endometrium. In addition to the gland-like structures in the uterine wall, there 
were many epithelioid, mononuclear, and giant cells, tubercles, and areas of casea- 
tion. Carbol-fuchsin stain showed acid-fast bacilli. In one portion of the posterior 
wall of the uterus, there was a circumscribed tumor which had the characteristic 
appearance of a fibromyoma. In the fundus and adjacent to the uterine cavity, there 
were the most extensive tuberculous lesions in tissue which was definitely adeno- 
myomatous in character. It was interesting to note that the tuberculous infection 
was situated around the glands in the endometrial stroma rather tlian in the 
myometrium. Much of the adenomyomatous tissue was replaced by caseous material. 
It was rare to find adenomyomatous areas without some form of a tuberculous 
reaction. The endometrium was the seat of an extensive tuberculous infection and 
in sections there rvas an extension of this endometrium for some distance up into 
the uterine wall. 

The walls of both tubes were slightly thickened and contained gland-like struc- 
tures which showed little or no cellular stroma around them. This was the condi- 
tion found in salpingitis isthmica nodosa, and according to Sampsonio in endometiuo- 
sis of the tube, the epithelium here had a tubal origin. In the region of the 
mucosa in the tubes, there were many tubercles, giant cells, and epithelioid cells. 

Tile ovary was converted into a cyst, the wall of w'hich contained only a small 
amount of ovarian stroma. The greater portion of the wall w’as formed of hyaline 
fibrous tissue in which were numerous gland-like structures varying in size and 
resembling those found in the walls of the tubes. Foci of mononuclear and 
epithelioid cells were present in the wall. Because of the excessive amount of 
caseous material present, ive were unable to determine the character of the epithe- 
lium which lined the cy'st, and hence could not classify tlie cyst other than to say 
that it was one of the cystadenomas of the ova^ 3 ^ 


DISCUSSION 

It is often impossible to determine the pnmaiy focus of infection 
m cases of tuberculosis of the female genital tract, but usually the 
fallopian tubes are involved and by extension the infection reaches 
the remaining pelvic organs. We are under the impression that this 
oecuiTed in our case. 

Our case is of interest in that it tends to support Cullen’s idea that 
adeiioinyoma arise from the uterine mucosa^^ and also in that it shows 
how the tuberculous infection reached the adenomyomatous areas, 
that is, by direct extension by way of endometrial tissue. 

iilocnch has shown that many of the cases reported as “tuberculous 
ovarian tumors” are only tubei’culous abscesses of the ovaiy. Such 
a conclusion as this might have been drawn from the gross findings at 
operation in our case, but upon histologic study, it is evident that we 
deal with a cj'stadenoma of the ovary associated intimately with a 
tuberculous infection. 



906 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


A study of the literature ou the subject shows that, with two excep- 
tions, all eases of the combination of tuberculosis and adenomyoma of 
the uterus have occurred in women who were more than forty-two 
years of age and who were also sterile. The two exceptions occurred 
in women twenty and twenty-two years of age. A majority of the 
patients gave a history of some type of menstrual disturbance. 

REFERENCES 

(1) Fraiikl, Oskar; Am. J. Obst. & Gynec. 10: 6S0, 1925. (2) Cullen, Thomas 

S.: Adenomyoma of the Uterus, W. B. Saunders Co. 1: 1908. (3) Williams, J. W.: 
Johns Hopkins Hosp. Reports 3: So, 1893. (4) Greenberg, J. p. ; Johns Hopkins 

Hosp. Reports 21: 97, 1924. (5) von Recklinghausen: Die Adenomyome und 

Cystadenome der Uterus und Tubenwandung, Berlin, 1896. (Ref. from R. W. 
Johnstone). (6) Johnstone, B. W.: J. Obst. & Gynec. Brit. Emp. 31: 243, 1924. (7) 
Dickson, Thomas C.: Am. J. Obst. 53: 799, 1906. (8) Cullen, Thomas S.: Myomata 

of the Uteius, 1908, W. B. Saunders Co., 335. (9) Moench, G. L.: Am. J. Obst. & 
Gynec. 6: 478, 1923. (10) Sampson, J. A.: Am. J. Obst. & Gynec. 10: 649, 1925. 

(11) Cullen, Thomas S.: Johns Hopkins Hosp. Reports 6: 133, 1897. 


GRANULOMA OF THE VAGINAL VAULT 

Nathan P. Sears, Ph.B., M.D., Syracuse, N. Y. 

A FAIRLY extensive search through the standard textbooks on gymeeology as well 
as other sources of medical information fails to reveal a record of a case 
similar to the one to be described. For this reason the following case seems worthy 
of record. 

Mrs. X., aged fortj'-six, consulted me on Oct. 10, 1931, for irregnlar vaginal 
bleeding which had been present for several weeks. Besides profuse and irregular 
menstruation there also was intennenstrual bleeding wMch appeared especially 
after intercourse. Her general healtli wms always excellent and there had been no 
operations. Her menstruation began at the age of fifteen and was regular in every 
respect until her present illness. She had been married four years and had had no 
children. Two years after her marriage there w'as a delay of menstruation followed 
by profuse bleeding but no sign of pregnancy was found. She rarely took douches 
and there was no other source of trauma. There had never been any evidence of 
a venereal infection. She had been told by one physician that she should have 
radium treatment for her present condition and by another that a complete 
hysterectomy was necessary. 

General examination was quite unimportant. Pelvic examination showed the 
uterus and adnexa to be normal. To the right of the cervix a soft velvety feel 
was noted. On withdraudng the examining finger, it was stained with blood. Recto- 
vaginal examination revealed no thickening of the vaginal wall. The speculum dis- 
closed in the right vaginal vault an irregular, granular elevated surface about 
3 cm. in diameter extending for about 0.5 cm. upon the lateral aspect of the 
cervix. The structure of tliis lesion was composed of small red tufts of granular 
tissue, the surface was glistening, showed very little evidence of necrosis, but it 
bled easily when touched. The lesion resembled slightly an epithelioma, but showed 
no induration, and its surface was clearer and more glistening than the usual 
malignant lesion. “Wassermann reaction was negative. The patient was sent to 



SEARS: GRANULOMA OP VAGINAL VAULT 


907 


the Syracuse Memorial Hospital where she was examined under anesthesia and the 
uterus curetted. The granular area was then, thoroughly removed hy the curette 
and all material saved for microscopic examination. The area left after removing 



He. 1. — Magniflcation X54. Shows the form and general structure of an individual 
unit. The inflammatory reaction is seen near the surface (top of picture) and the 
connective tissue background at the base. Note the tortuous blood vessels through- 
out tlie entire section. 



^ 2. Magnification X230. Note the connective tissue background, the dilated 

capillaries and inflammatory cells. 

the granuloma was flat and mottled with blood points. It was lightly sprayed with 
'e coagulation current of tlie higli frequency inncliine. 


908 


AMERICAiSr JOURNAL OP OBSTETRICS AND GYNECOLOGY 


Pathology Report; Specimen consisted of about 2 e.c. of uterine mucosa of 
normal appearance, and about 1 c.e. of soft granular material from the vagina. The 
individual tufts of this were about 1.5 mm. in diameter, glistening, and congested. 
Blocks were made separately of the endometrium and the tissue from the vagina. 

Microscopic Examination: The endometrium showed normal interval reaction. 
Under low magnification (Fig. 1) the section of vaginal tissue was seen to consist 
of roughly triangular pieces of tissue. It was evident that the narrower part of 
these provided the base b}' which they had been attached to the vaginal mucosa. 
Under slightly higher magnification (Fig. 2) the structure of each of these small 
triangular pieces of tissue was seen to consist of a fairly compact connective tissue 
stroma. In the outer third there were many inflammatory cells packed densely into 
the stroma, tortuous capillaries filled with blood, and considerable extravasation of 
red blood cells into the tissue. Toward the base, the inflammatory reaction gradually 
disappeared until it was found to be entirely absent in the proximal third. Here 
was seen wide bands of connective tissue and large tortuous vessels. Under still 



Plgr. 3. — Magnification XIOOO. The types of cells are shown. Note the fibroblasts and 

plasma cells. 

higher magnification (Fig. 3) the inflammatory cells are seen to consist of leucocytes, 
lymphocytes, eosinophiles, fibroblasts, swollen connective tissue cells and many 
plasma cells. The connective tissue bauds were considerably broken up and separated 
by this reaction. The capillaries were filled witli blood, and there were several 
areas in which many red blood cells were free in the tissue. 

Diagnosis: Simple granuloma resembling granuloma pyogenicum. 

Further Treatment: Patient returned to the office for weekly treatments. On 
November 12 and 19 the unipolar desiccation current was applied. Her next treat- 
ment was December S. She was unable to return sooner because of a mild phlebitis 
in the calf of her right leg which apj)eared soon after the previous treatment. On 
this date the area was much smaller and desiccation was again applied. From then 
on the area graduallj^ diminished and silver nitrate was applied at tri-weekly 
intervals. On January 17 the area was 3 mm. in diameter. On the twenty-eighth 
it was healed completely but bled when touched. On February 7 the patient was 
discharged healed and has had no recurrence. There have been two profuse 
menstrua] periods, apparently due to nienopau.«e dysfunction. 




VliSELL : 


FRIEDIMAN' PREGNANCY TEST 


909 


DISCUSSION 

Tlie case presents the characteristics of a simple granuloma. Histologically it 
resembles the so-called granuloma pyogenicim, so often found on the skin and 
mucous membrane of the mouth. It differs, however, in that the pyogenic granuloma 
is usually a pedunculated or sessile tumor. So far as I have been able to find 
there is no previous report of such a lesion in the vagina. 

505 Medical Arts Building. 


A MODIFICATION OP THE FRIEDMAN PREGNANCY TEST 

Morton Veselu, M.D., New York, N. Y. 

T he proposed modification of the Friedman test is based upon an 
experience in 883 cases, in some of which the original Aschheim- 
Zondek test tvas employed and in others, the original Friedman method. 
Tlie percentage of accuracy attained with the Aschheim-Zondek test 
was 99.2 per cent in my hands, with the Friedman test 89 per cent. 
Wliile the Aschheim-Zondek test has an aecnraey approaching the 100 
per cent ideal, it nevertheless, has certain disadvantages which were 
avoided in the Piiedman modification. It was, therefore, deemed 
desirable to attempt to modify, if possible, the technic still further 
and try to approach an ideal. 

The technic adopted is as follows : 

1. The first morning specimen of urine is used. Urines nmy be kept, when 
neccssaiy, for varied lengths of time. (One specimen of urine gave a positive 
reaction after being kept in the ice box for one year.) 

2. The ear vein of the rabbit is dilated with ether and 7 c.c. of the first morn- 
ing urine is injected intravenously. The marginal vein is preferred as it is the 
most fixed. 

3. Any female rabbit, weighing not less than IGOO gm., irrespective of its 
maturity has been employed as test object. However, virgin rabbits arc pre- 
ferred. The picture of the ovaries of mature and even of pregnant rabbits after 
injection with urine of nonpregnant and of pregnant women is so easily differ- 
entiated that it makes veiy little difference to the experienced technician as to 
the type of animal used. The effect of the urine of pregnant women upon the 
ovaries of mature nonpregnant rabbits, as well as upon the ovaries of pregnant 
rabbits, may be described as superovulation. Animals weighing le.«s than IGOO 
gm. should not bo used as they may be too young to react to the hormonal 
stimulation. 

4. The injection is given verj* slowly with a 10 c.c. .syringe and ordinary hypo 
needle at the rate of 1 c.c. per minute. (Should the animal show any untoward 
reactions, the intravenous injection of 1 c.c. of coramine is administered. This 
drug has actually saved a number of rabbits that surely would have died.) 

o. The animal is opeiutcd upon or killed by the intravenous injection of air at 
the end of forty-eight hours and the ovaries examined. The injection of 10 to 
40 c.c. of air is quickly effective. This procedure was found more satisfactoiy 
than gas, ether, chloroform or the rabbit blow which were used in the early tests, 
G- A itositive result, indicating pregnancy, is judged solely by the presence of 



910 AJIERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 

corpora hemorrliagica. This finding is pathog-nomonie for the presence of the 
hormone in the urine of pregnancy and cannot be mistaken for the changes in 
the, ovary occurring in a spontaneous pregnancj^ in the test animal. 

7. Gross examination sufiiced in 100 per cent of the cases. There are no doubt- 
ful cases, the results being either distinctly positive or negative. 

The above procedure is used routinely’- in all eases where the amenor- 
rhea has exceeded ten days and differs from the original Friedman 
test as follows: (1) 7 e.c. instead of 5 c.c. of urine is injected. (2) 
Autopsy is performed in forty-eight honrs instead of twenty-four 
hours. (3) Female rabbits of any size, weighing at least 1600 gm. 
instead of virgin rabbits may be used. 

The majority of errors occur in eases of amenorrhea of ten days’ 
duration or less. For this group of patients the method has been fur- 
ther modified as follows: (1) The initial injection is given exactly 
as above. (2) The same rabbit is reinjected with 7 c.c. of the same 
urine, tiventy-four hours after the first injection. The nrine is kept 
in the ice box between injections. (3) Autopsy is performed forty- 
eight hours after the initial injection. 

This variation in procedure, in cases of very early amenorrhea, has 
enabled me to eliminate the errors encountered in earlier experience. 
Ninetj'- per cent of the errors with the original Friedman test, in my 
series, were in cases of amenorrhea of less than ten dajds. 

DIAGNOSIS OF DEATH OP THE FETUS 

The Asehheim-Zondek test and all its modifications have also been 
used in diagnosing the death of a fetus. In this respect the various 
tests have given rather disappointing results. Most observers have re- 
ported that the Friedman test becomes negative within seven to fonr- 
teen days after the death of the fetus. Nevertheless, in this present 
series of cases a positive result has been obtained as late as the sixth 
week after the death of the fetus. The time it takes for the urine to 
become negative after the fetus dies api^ears to depend somewhat on 
the stage of gestation. Observations upon this point, in mj'- series, 
maj^ be summarized as follows: 

1. "When a Friedman test proves negative in a case of previous!}' proved preg- 
nancy, it indicates feta] death. 

2. When the clinical signs indicate fetal death and the second Friedman test 
is still positive, the latter does not necessarily contradict the clinical diagnosis 
because the fetus may be dead and the chorionic elements may still retain their 
viability. This can persist for from four to six weeks after the death of the fetus 
and has been borne out by cases in wJiich a second positive test was reported 
twenty-four hours before the patient was delivered spontaneously of a six months 
old, macerated fetus. 

3. In ectopic pregnancy, positive results have been recorded up to three and 
a half weeks after the onset of vaginal bleeding and in several cases where there 
was only slight spotting, up to four weeks after the initial day of spotting. This 



ROSENFELD; ABRUPTIO PLACENTAE 


911 


necessarily involves the acceptance of the theory that vaginal bleeding is a sign 
of death of the fetus in cases of ectopic pregnancy. 

4. In this series, where the pregnancy reached the period of viability and 
subsequently the fetus died, the test remained positive for a longer period than 
two weeks. All eases of incomplete abortion and full-term pregnancy, in this 
series, gave negative results within two weeks after the clinically suspected ter- 
mination of the gestation. 


SUIMMARY AND CONCLUSION 

1. The Ascliheim-Zonclek test and its modifications have been car- 
ried out in 883 eases. In the total there was an accuracy of 98 per 
cent. The original Asehheim-Zondek test performed with mice, in 
250 cases, shoAved an accuracy of 99.2 per cent. The Friedman test 
carried out in 100 cases, with rabbits, gave 89 per cent accurate re- 
sults. The present modification, adopted in the last 533 cases, of this 
series, shoAved 100 per cent accuracy. 

2. A positive result has been obtained after the death of a fetus for 
a period of four to six Aveeks in gestations of six months’ duration 
or more. 

302 Wkst Ninetieth Street. 


PREGNANCY AND LABOR SUBSEQUENT TO ABRUPTIO' 
PLACENTAE AND UTEROPLACENTAL APOPLEXY* 
Samuel S. Rosenpeld, M.D., P.A.C.S., Neav York, N. Y. 

W HILE the textbooks and most of the papers on the subject go 
quite thoroughly into the matter of immediate prognosis, prac- 
tically none of them as much as mention future prognosis. Of the 
standard obstetric textbooks that I haA-^e consulted only DeLee touches 
on the question of recurrence of abiuiptio placentae and he says, 
“Abruption may recur in subsequent labors.” Tavo of the largest and 
most Avidely knOAvn obstetric institutions in the country could furnish 
me Avith no statistics on the matter of recurrence. There is also a 
marked lack of data as to the futiu'e of patients aa'Iio have had abruptio. 
This paper is an attempt to build up a statistical structure so that 
these important prognostic questions may be ansAvered. 

Within the last five years, I have personally treated fifteen patients 
with abruptio placentae. All of these cases could be classified as 
severe. Seven of these Avomen Avere priiniparas, five Avei*e secundi- 
paras, one Avas a tertipara, one a quadripai-a and one of unlaiOAvn 
parity. Five cases Avere of the extreme tAqie of abruptio, namely 
uteroplacental apoplexy. 

oolo^^Maf 24? 1932^’""' Section on Obstetrics and Gync- 



912 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


In my series of 15 eases, tlie apparent causes of abruptio placentae 
were toxemia in 12, infection in one, profound mental emotion in one, 
and in the remaining one no cause could be ascertained or assigned. 
Uteroplacental apoplexy occniT’ed five times. Eclampsia was present 
once. In this series there Avere 15 patients Avith one recurrence mak- 
ing 16 eases of abruptio placentae in all. Of these, 7 patients deliA^- 
ered spontaneously. I delivered one by Ioav foi’ceps, one by internal 
podalic version and breech extraction, 2 by breech extraction and 5 
by cesarean section. In 2 patients, I introduced bags and both delw- 
ered spontaneously. I encountered the Couvelaire type of uteims 5 
times. 

Of these 15 Avomen, I have subsequently delivered 5. The histories 
of these 5 cases are as folloAvs : 

E. R., aged tAventy-four, para ii. One year ago she liad a p)remature separa- 
tion of the placenta at full term, and was told, by her family doctor at the time, 
that she had kidney trouble. I Avas called in consultation and AA'ith conseiTath’e 
treatment she Avas delwered of a stillborn infant. She made a good recovery. 
She became pregnant shortly aftei'Avards, was on a diet that contained very little 
protein and showed no evidence of toxemia, such as rise in blood pressure or 
albumin in the urine until about two Aveeks before term. Her pressure then rose 
moderately and small amounts of albumin appeared in the urine. On the day of 
admission to the hospital she began to bleed and had abdominal pain of moderate 
severity. Her condition Avas fair. The fetal heart could not be heard. The 
uterus was board-like, the cervix aa’us two fingers' dilated, and the membranes 
Avere intact. I decided to treat her conservatively. I ruptured her membranes, 
packed her, and gave small doses of pituitrin. The bleeding, however, continued 
and her condition grcAV Avorse. I therefore transfused her and performed a trans- 
peritoneal extraperitoneal cesarean section under local infiltration anesthesia. The 
uterus presented the typical picture described by Couvelaire as uteroplacental 
apoplexy. The fetus was dead. The placenta wms lying loose and the uterine 
cavity was filled with blood clots. The uterus contracted in a satisfactory man- 
ner and I therefore closed the uterine and abdominal incisions. Her convalesence 
Avas marked by the development of a pelvic abscess, which Avas opened and drained 
per vaginam. She left the hospital in good condition. 

R. E., para ii, aged twenty-seven. Her prcAdous labor four years ago was com- 
plicated by abruptio and eclampsia. Her present pregnancy was uneventful except 
for some staining or very scant bleeding early in her pregnancy. This subsided 
after rest in bed and calcium therapy. Blood pressure, urine and blood chemistry 
determinations were normal throughout the pregnancy and the puerperiuih. She 
Avas delivered spontaneously of a living baby. 

S. H., para ii, aged twenty-five. Pirm years previously I performed a cesarean 
section on this patient because of a A'ery grave form of abruptio placentae. The 
uterus was an extreme example of the CouA'claire type. Her intervening history 
AA’as irrelevant except for an obstinate peripheral neuritis. Her pregpiancy was 
uneventful, the urine and blood pressure were normal throughout. I delivered 
her of a living child by classical cesarean section. She made an uneventful 
recovery. 

R. "W., para ii, twentj’-four years old. I had performed a classical cesarean 
section under local anesthesia on this patient two years previously, because of 



KOSENFELD : 


ABRUPTIO PLACENTAE 


918 


abruptio placentae and toxemia of pregnancy, as evidenced by a blood pressure 
of 190/100, four plus albumin, and granular casts in the urine. In addition there 
was present an atresia of the vagina and cervix making vaginal delivery impos- 
sible. Two years later, I did a classical cesarean section under general anes- 
thesia. I performed this operation before the onset of labor. On opening the 
peritoneal cavity, I found a hole in the uterus about the size of a silver half 
dollar near the fundal end which W'as plugged by the amniotic sac. The uterine 
muscle about this area was very thin and stretched. I delivered a normal living 
infant and sterilized her. She made an uneventful recovery. During this preg- 
nancy her blood pressure and urine were normal. 

C. G., para ii, aged twenty-three. During her previous pregnancy at about 
term she developed a toxemia of pregnancy and a moderately severe form of 
abruptio placentae. I ruptured her membranes and introduced a bag into the 
cervix and she was delivered spontaneously of a stillboni child. One year later, I 
delivered her normally of a normal living infant. Her urine and blood pressure 
were normal throughout pregnancy. She is pregnant again. 

I tried in tliis series of cases to employ the conservative plan of 
treatment wherever possible. This consisted in an initial dose of 
morphine, artificial rupture of the membranes, tight vaginal packing, 
and hj'^podermic injections of small doses of pituitrin when the labor 
pains were weak, or absent. 

My practice now in the grave eases is to transfuse and then perform 
cesarean section under local infiltration anesthesia. In cases of utero- 
placental apoplexy, Polak favored cesarean section followed by hys- 
terectomy, As stated above I have had five eases of proved utero- 
placental apoplexy. I have subsequently delivered two of these women 
of normal living infants by classical cesarean section. 

In the treatment of the Couvelaire type of uterus, it seems to me 
that in the majority of cases, hysterectomy would be too radical a 
procedure. I believe that in such cases, the uterus should be watched 
for a minute or two and if it shows contractile power it should be 
saved. The uterine muscle is apparently damaged however and 
in subsequent labors, those women who were treated by cesarean sec- 
tion should again be similarly treated, preferably before the onset of 
labor. 

Pregnancy was obseiwed in five patients in this series after abruptio 
placentae. Pour of these women had an uneventful pregnancy and 
labor and gave birth to living children. In one patient abruptio pla- 
centae recuiTed, and she was delivei’ed of a stillborn fetus. 

A woman having abruptio placentae need not necessarily be advised 
to avoid pregnancy for her chances of having a normal pregnancy and 
labor are good. 


1882 Gr.\nd Concourse, 



REPORT OP A CASE OP RUPTURED OVARIAN CYST IN 

THE NEWBORN'^ 

Samuel M. Dodek, M.D., M.A., Washington, D. C. 

17 ABLY ill the iiioiniiig- of Dee. 11, 1931, Mrs. S. H., a white Polish woman 
•*— ' aged twenty-eight, was admitted in active labor at term, to the Obstetrical 
Division of the Cleveland City Hospital for care. She had had four previous 
pregnancies, each spontaneous and uneventful at full term. 

Labor began at 2:00 a.m. of the day of admission and full dilatation of the 
cervix was attained at 5:30 a.m., the membranes having ruptured at 4:30. After 
the patient was scrubbed for deliver}', the fetal heart was 144 and the fetus was 
presenting in the persistent right oeeipitoposterior position, at a low midpelvic 
plane. I rotated it to an anterior position by the modified Scanzoni maneuver 
of Bill. Eeapplication of the forceps followed at once, and extraction was attempted. 

The head was delivered with very little difiSeulty, but difiiculty was encountered 
when an attempt was made to deliver the anterior shoulder under the symphysis 
pubis. Gentle, but firm, ti'action on tlie head with additional aid received from 
pressure on the fundus by an assistant, were of no avail. Since the patient had a 
markedly relaxed pelvic floor it was not difficult to insert the hand into the birth 
canal along the anterior surface of the baby’s chest, partially extend the anterior 
forearm and manually extract that member. The shoulder then followed easily. 
Dorsal traction on the fetus effected the delivery of the posterior shoulder over 
the perineum and the arm and forearm were extracted with a fair amount of ease. 

After the bisacromial diameter had passed the vaginal outlet, difficulty was 
again experienced when an attempt was made to extract the trunk. Again with 
pressure on the fundus and with traction from below, a fullterm baby girl weigh- 
ing 3,850 gm., with marked abdominal ascites, was delivered at 6:14 a.m., forty- 
four minutes after the onset of second stage labor. The baby breathed at delayed 
inteiwals for one hour, but all attempts at resuscitation and stimulation failed to 
keep it alive. 

The third stage of labor was terminated quickly and the mother was returned 
to her own bed in good condition, sufifering from no visible new lacerations of 
an already relaxed perineum. On the eleventh day postpartum she was discharged. 

A postmortem examination of the infant was done five hours after death. 

Externally the thorax was symmetrical and when that cavity was opened (which 
procedure followed opening the abdomen) the lungs were found to be filled with 
air and they did not collapse. No fluid was found in either pleural cavity and 
the pericardium was smooth and the heart small. 

The abdomen was markedly distended and tense, and dull all over to percussion. 
On opening the abdomen a large amount of hemorrhagic material was found in 
the peritoneal cavity. The dome of the diaphragm was at the third rib on the 
right and the fourth on the left. The lower border of the liver extended 1 cm. 
below the free costal margin in the right midclavicular line. The gall bladder 
and intestines, which were displaced to the left and upward by a mass extending 
into the abdominal cavity from the pelvis, appeared normal. No gross changes 
could be demonstrated in the spleen, adrenals or urinary system. 

•Presented before the Obstetrical and Gynecological Section of the Academy of 
Medicine of Cleveland, May 11, 1932. 


914 



DODEK: RUPTURED OVARIAN CYST IN NEWBORN 


915 


The uterus was normal, measuring 2 cm. in length. The left tube and ovary 
presented no abnormalities and the right tube, too, seemed normal. The broad 
ligaments were also normal. However, occupying the site of the right ovary was 
a cyst (Fig. 1) measuring 12 cm. in diameter which occupied the major portion 
of the abdomen. 

The surface of the cyst was smooth and at the upper border there was an 
irregular linear tear measuring 3 cm. The contents were made up of bloody 
material estimated at 300 c.c. (including that which had escaped into the peri- 
toneal cavity through the tear) and when the contents were removed the inner 
surface appeared covered by a layer of fibrin. The wall was thick at the base, 
the site of the original ovary, but very thin in the region of the tear. 

A histologic examination was made by Doctor David Seecof, Director of Lab- 
oratories in the Cleveland City Hospital. 



Fig. 1. — A photograph of the gross specimen showing tlie uterus, adnexa, and tlie cyst 

replacing the right ovary. 

Fig. 2, a low-power microphotograifii of the base of the cyst demonstrates at 
one end, a narrow zone of compressed ovarian tissue containing a moderate num- 
ber of ova (Fig. 3). The remainder of this section is made up of a scantily 
cellular and stringj- fibrous tissue lined internally by a well-defined layer of flat- 
tened and elongated endothelial-like cells containing a few scattered lymphocytes. 

The diagnosis was made of follicular cy.st of the right ovarj’. 

The left ovary was normal except for edema of the interstitial tissue. 

Other reports of ovarian cysts including simide cysts, sarcomas, and carcinomas 
occurring in young children, in the fullterin newborn and in the premature infant, 
have appeared from time to time in the literature which is available for investi- 
gation; but the case presented here as far as I can determine, is the largest on 
record for a fulltenn newborn baby and the only one which I have been able to 
find which was the cause of dystocia and very early neonatal death. 

Kellyi in 1889 tabulated 126 cases of benign and malignant tumors of the 
ovaries in young females, which had been operated upon. The youngc.=t, a patient 
of D'Arcy Powers,^ was four months old. 




916 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


Included in the Transactions of the Pathological Society of London for 1889, is 
a report by Alan Dorans of the finding of bilateral ovarian cysts in a seven-month 
fetus. 

In 1891, Beale of England* reported the autopsy findings of a six-week-old 
infant which died four days after the onset of symptoms of peritonitis. A puru- 
lent fluid was found in the peritoneal cavity and the pelvis was filled with pus. 
Attached to the right ovary were the remains of “a small ruptured cyst.” 



Fig. 2. — Low-power mlcrophotograph of the base of the cyst showing, at the right bor- 
der, the remains of the ovary and the inner layer of the sac. 



W. A. Downess in 1921 reported a case in which a swelling of the abdomen 
was noted at birth. The distention gradually increased until at the age of seven 
months, when the infant was seen by Downes, a diagnosis of ovarian cyst was 
made and a simple cyst successfully removed. It is Downes’ impression that these 
tumors may reach a considerable size in the fetus and that the earlier they make 
their appearance, the better the chances are that the growth is benign rather than 
malignant. 

A right ovarian cyst wliich became twisted and strangulated the body of the 
uterus and left tube and ovary, necessitating entire removal of all the internal 




DODBK : RUPTURED OVARIAN CYST IN NEWBORN 


917 


genitalia, was reported by E. M. Powell® in 1923, in a five-montli-old infant. The 
operative result was said to be good. 

V. Franque,7 1909, reported a pedunculated unilocular cyst of the left ovary, 
which he discovered during the postmortem examination of an infant which died 
eighteen hours after birth. The cyst was round (4 cm. in diameter), intact, and 
its pedicle was twisted three times on itself. Microscopic examination of the 
specimen revealed some ovarian parenchyma, and he called it a cyst of a graafian 
follicle. The right ovary in the same subject contained a small cyst the size of 
a pea. 

One of the most recent contributions to this subject is by H. O. Neuman® of 
Germany. During a postmortem examination to determine the cause of death of 
a fetus which occurred eighteen hours before the onset of the second stage in a 
primiparous labor, he discovered a right ovarian cyst somewhat similar, macro- 
scopically, to the one reported in this paper. His specimen was smaller, however, 
measuring 10 by 9 by 8 cm., and was unruptured. The suspensory ligament on 
the side involved was absent and there were no cystic changes in the opposite 
ovary. Microscopic examination showed connective tissue and numerous blood ves- 
sels near the lumen of the cyst but no evidence of ovarian tissue was seen. Neu- 
man believed that the parenchyma of the original ovary was possibly destroyed 
by the rapidly enlarging tumor, and that the stroma had been so markedly dis- 
integrated that it could not be recognized as such. For these reasons he ventured 
no classification of his specimen. 

H. A. Harris® about two years ago, described two multilocular cysts of the 
ovary found during a routine postmortem examination of a two-month-old infant 
which had died of bronchopneumonia. 

DISCUSSION 

Justification for the presentation of this single case report lies, I believe, in 
the facts that this condition is not usual; that this particular cyst was larger 
than any hitherto reported, and that it was sufficiently large to cause a moderate 
dystocia. Death of the infant was due to rupture of the cyst, and associated 
internal hemorrhage brought about by the disproportion encountered during de- 
livery of the infant’s trunk. 

I desire to express my appreciation to Dr. A. H. Bili, of Cleveland, for permission 
to report this case. 


REFERENCES 

(1) Kelli/, H. A.; J. M. Keating’s Cjxlopedia of Diseases of Childhood, Med- 
ical and Surgical, 1889, Philadelphia, Lippincott. (2) Powers, D’Arcy: Brit. 
M. Jour. p. 850, 1898. (3) Doran, Alan: Transactions of the Pathological So- 
ciety of London, 1889. (4) Beale, George B.: Brit. M. J. 2: 255, 1891. (5) 
Downes, W. A.: J. A. M. A. 76: 443, 1921. (6) Powell, E. M.: Lancet 1: 751, 

1923. (7) Von Franque: Ztschr. f. Geburtsh. u. Gyniik. 39: 330, 1909. (8) 

Neuman, K, 0.: Monatschr. f. Gmak. u. Geburtsh. 75: 12a, 1927. (9) Harris 

K. A.: J. Anat. 64: 305, 19.30. 

1835 Eye Street, N. W. 



THE TREATMENT OF ASPHYXIA IN THE NEWBORN BY LUNG 
INPLATOR FOR INDIRECT MOUTH-TO-MOUTH 
BREATHING 

Pierce JMacKenzie, M.D., Evansville, Ind. 

'^HE essential care of the newborn baby that does not breathe spontaneously 

after the air passages are cleaned out as well as possible with a catheter, is to 
maintain the body temperature by putting the child into warm water and to 
inflate the lungs with expired air which contains oxygen and also carbon dioxide. 

Tliis inflation may be accomplished by means of a catheter in the trachea as 
recommended bj’ DeLee; bj’ means of apparatus such as devised bj' Henderson, 
Flagg or Kreiselman which delivers oxj'gen or a mixture of oxj-gen and 5 to 10 
per cent carbon dioxide from a tank; or by moutli-to-mouth breathing. 

The tracheal catheter has proved satisfactory to manj' but there is a con- 
siderable amount of skill ueeessarj' in introducing the catheter into the trachea 
with a possibility of injurj’ to the throat by rough examinations; especially is 
this true in the premature newborn of seven to eight months’ gestation. There is 
the necessity of repeated introductions of the catheter when the air passages con- 
tain mucus or blood which must be removed from time to time and there must be 
a careful estimation of the amount of air pressure used so that no damage be done 
to the lung cells. 

The various apparatus on the market are expensive, not easily transported when 
deliveries are made in different places, and thej’ or the gas tanks are frequently 
out of order on the surprise occasion. 

Direct mouth-to-mouth breathing, although successful from early histor}-, is not 
easy to establish and is dangerous to the infant’s lungs because of the indefinite- 
ness of the pressure applied. It is very disagreeable and also dangerous to the 
obstetrician because of the possibility of infection. 

Expired air offers a logical stimulus to respiration as it contains both oxygen 
and carbon dioxide in considerable amounts. Howell gives the percentage of 
oxygen between 11 and 17 per cent and carbon dioxide between 3.7 and 5.5 per 
cent. I believe it is practically as efficient as the gases supplied from tanks. 

I have found that at times ammonia acts as a definite respiratory and cardiac 
stimulant. Too much must not be used as it may produce edema of the mucous 
membrane by irritation. 

I have devised an apparatus whereby mouth-to-mouth breathing may be car- 
ried on with no intimate contacts, mth a definite control of pressure to the baby’s 
lungs and with the possibility of using ammonia at the same time if desired. If 
the combination of gases obtainable in tanks is thought advantageous, the face 
mask of this apparatus, without the breathing tube, may be attached to a standard 
g-as machine breatliing tube having such a tank, and the gas administered as 
recommended by Henderson. I have found the mouth breathing method as here 
described satisfactory. 

The apparatus may easily be carried in the physician’s bag or pocket and is 
inexpensive. It can easily be at hand anjTvhere when needed when the baby is 
bom in poor condition due to the injudicious use of morphine or pituitrin during 
labor, or after a delivery with a general anesthetic, after cesarean section, or when 
due to an accident to the fetus’ circulation during normal or prolonged labor the 
baby is bom unable to breathe spontaneously. 

918 



MAC KENZIE : TREATMENT OP ASPHYXIA IN NEWBORN 


919 


The apparatus consists of a rubber mask to fit a newborn’s face, a mouthpiece 
and tube for the doctor to breathe into, a spring gauge with indicator to control 
the pressure of the air delivered to the child’s lungs and a container for aromatic 
spirits of ammonia on cotton which may be opened into the air passageway. 
The breathing tube may be detached from the mask to allow attachment to a 
standard gas machine for ox.ygen or a mixture of oxygen and carbon dioxide from 
a tank if desired. 

All fluid, blood and mucus are removed from the baby’s mouth and nostrils 
as soon as the head is born. The nose and throat are sucked free of fluid by a 
catheter with the child’s head held down, and if the asphyxia is of the serious 
type, the child is placed in a water-bath at the proper temperature. The doctor 
himself or a nurse supports the baby’s shoulders and head so the neck is straight, 
and the mask is placed to cover the baby’s nose and mouth. The breath is 



Pig. 1. — Lung inflator. A, Special infant size rubber mask ; B, adjustable gauge for 
pressures delivered ; C, cup for aromatic spirits of ammonia ; D, cutoff for ammonia 
into airway. 

exhaled in puffs through the mouthpiece at the rate of about thirty to forty 
per minute with the spring set at the proper mark to blow off at more than one 
one-hundredth of one atmosphere or about 6 or S mm. mercury pressure. Slightly 
more pressure may be found better. This is readily obtained by adjusting the 
spring gauge. The throat is kept clear of fluid by the catheter as needed. The 
baby’s heart action is watched by observing the pulsation at the navel or neck. 
.(Ynuuonia may be let into the airway by opening the cutoff as desired. If pro- 
longed efforts are necessary, the baby’s tongue is best pulled forward by putting 
a suture through the tip of the tongue and traction is made on the suture by 
pulling it under the edge of the mask. This opens a more direct, unobstructed 
passage into the trachea. 

A few drops of pituitrin or suprarenalin hypodermatically may be used to 
stimulate the circulation. 

I have observed temporary stimulation of respiration by alpha-lobelin, but I 
do not consider it sufficient in itself in severe asphyxias, 

American Trust Building. 





TRUE,''SAECO]\IATOUS CHANGE IN A UTERINE FIBROID . 

I 1 ? 

Paul D. Scofield, M.D., Columbus, Ohio 

'T'HE question of malignant cliange of leiomyomas of the uterus is still somewhat 
^ misunderstood. For a good many years gjmecologists and surgical pathologists 
have been searching through wide areas of benign tumors, and on finding suspicious 
foci they have tabulated these as sarcomatous changes, thus multiplying the number 
of cases of malignancy. It can be shown that many such foci are not of clinical 
interest because they do not represent the beginning of a true malignancy, but rather 
an acceleration of growth which is often temporary in nature. However, the 
following case represents an instance of true malignancy in a uterine fibroid. Its 
presentation is warranted not onl}' because of its comparative rarity, but also be- 
cause it should teach us to attempt to correlate the histologic picture with the 
management of the ease. 

Patient, aged forty-five, first seen May 13, 1930 complaining of lower left abdom- 
inal pain and vaginal bleeding. These symptoms began four months before and 
were constant. Bleeding varied from a scanty to a profuse amount. Pain was 
dull and aching, radiating to the left hip. During the previous two months she had 
a sensation of fullness in her abdomen and thought that it had increased in size. 
She was admitted to the hospital Maj' 14, 1930. Urine and blood were normal. 
The hemoglobin was 85 per cent. Family history was negative for malignancy. 
Her general condition was good. Tlie pliysieal examination was negative except for 
abdomen. There was tenderness and some rigidity in the lower left quadrant. 
There was a palpable symmetrical mass about the size of a four months pregnant 
uterus. The vaginal examination confirmed the above. 

The patient was operated upon May 15, 1930. Under ether anesthesia a midline 
incision was made exposing a uterus enlarged to the size of a grapefruit, containing 
many fibroids; it was rotated to the right, upon the cervix, with a resulting chronic 
inflammation of the left tube and atrophy of the ovary. A routine panhysterectomy, 
left salpingo-oophorectomy, and appendectomy were done. The pathologic report 
was as follows: “Uterus measures 10 cm. very much distorted by fibroid growths. 
One measures 4.5 cm. in diameter, filling the body of the uterus, with several smaller 
ones in the wall, and a larger growth at one side, about 7.5 cm. in diameter which 
is rather friable. On section the center appears to be undergoing a degenerating 
process with the surface markedly roughened. Microscopic diagnosis: Leiomyomata 
undergoing sarcomatous change. Chronic salpingitis, sclerotic ovary, chronic ap- 
pendicitis. ’ ’ Convalescence was uneventful and the patient left the hospital on the 
twenty-sixth day after operation. 

Patient was not seen again until May 2, 1931. At this time she complained of 
severe pain in the right hip. X-ray of the pelvis showed a “moth-eaten appearance 
of horizontal ramus of right pubic bone, resembling malignancy.” Physical ex- 
amination was negative, except for a hard mass in the old incision about the size 
of a half dollar. Patient stated that she became lame on February 25, and was 
compelled to go to bed April 10 because of the severe pain whicli was constant in 
the region of the right hip. On admission to the hospital, the urine contained 100 
mg. of albumin with hyaline casts. Two days later it was negative. Blood count 
was normal, and the hemoglobin was 90 per cent. 

Biopsy was decided upon and on May 4, an incision was made through the old 
scar and over the mass. This latter was found to be larger than suspected and 


920 



WITHKRSPOON : ASOKRTAINING SEX OP NT2WBORN 


921 


iuvolWd not only tlie abdominal wall, but also the fascia and peritoneum. The 
peritoneal cavity was opened and the entire pelvis and lower abdomen was found 
to be the seat of a sarcomatosis. The pathologic report was ‘ ‘ spindle-cell sarcoma. ’ ’ 
The patient became progressively weaker and died June 21, 1931. 

The essential feature of the autopsy was the confirmation of the operative find- 
ings. The lower abdomen and pelvis were filled ndtli leiomyomatous nodules, whose 
microscopic appearance was exactly the same as that of the original tumor. 

We have in this ease the recurrence of a uterine fibroid and its fatal termination. 
Malignancy in this type of tumor is of two kinds: (1) Recurrence and overgrowth 
because the primary tumor was actively growing and of such a nature as to be 
difficult of removal. In this type apparently some of the growth is left behind. 
No difficulties were encountered in this particular case, however, in the removal 
of the growth. Hence it falls into the second class, (2) true malignancy. In 
this latter type there is always some variation from the ordinary fibroid in the 
histologic structure, although these variations, as in this case, are not marked. It 
is the occasional occurrence of the suspicious foci in uterine fibroids that make it 
decidedly worth while to carefully watch the character of the apparently degenera- 
tive changes and study them for possible malignancies. 

283 East State Street. 


A SIMPLE PKOCBDURE OP ASCERTAINING THE S EX OP 
THE NEWBORN, WHERE THE DIAGNOSIS IS DIPpToULT 
DUE TO ■ G ENITAL ABNORM ALIT-IESJ 
J. Thornwell Witherspoon, M.A., Oxon., M.D., New Orleans, La. 

r TNFORTUNATELY the laity places a stigma, amounting almost to disgrace. 

upon any condition resembling half male and half female, and naturally 
enough this form of pseudohermaphroditism is the first thought that the Inyman 
lias when he learns that the sex of his neighbor’s child is uncertain. No mother 
wants it known among her friends that the sex of her long awaited baby is 
doubtful; nor would any mother enjoy having to tell her friends that her newly 
arrived son had turned out to be a daughter. 

The solution to this distressing and embarrassing problem lies in the doctor’s 
ability to make an immediate and correct diagnosis of the sex of the baby at the 
time of delivery, and thereby keep within the family circle the loiowledge of anj* 
congenital sexual abnormality. But such accurate diagnosis is not always easy, 
and the very simple procedure of catheterizing whatever genital orifice that pre- 
sents itself is offered as an additional aid in the determination of the true sex. 
If urine is obtained by this maneuver, the orifice is undoubtedly the urethra, and 
the child can be safely called a male. However, if urine is not immediately 
obtained, not even after a second catheterization, or if urine escapes around the 
base of the catheter, the child can be correctly diagnosed a female, since the 
orifice must lead into the vagina. However, in spite of all methods of examina- 
tion, some cases are encountered in which abdominal oper.ition is the only means 
whereby the true sex of the infant can be determined. 

At a recent delivery the baby's genitalia. Pig. 1, presented a small orifice at 
the base of an organ that could have been an abnormal penis or an enlarged 
clitoris. The perineal raphe extended posteriorly from this orifice, bisecting two 
folds of tissue that re.semblod the labia majora; no testicle could be palpated in 



922 AjMERICAN journal of obstetrics and gynecology 

either fold. An immediate determination, of the sex of this baby was impossible 
by the usual methods of examination, since the condition could have been either 
a marked hypospadias, with bilateral undescended testicles, or a partially im- 
perforated vagina with an enlarged clitoris. 

Five doctors in all saw this condition before any internal examination was 
made; three diagnosed the baby as female, two as male. The child was then taken 
to a hospital and cystoscoped, and the orifice between the labia majora-like struc- 
tures was found to be the urethra, not the vagina; in consequence, the condition 
was diagnosed as a case of marked hypospadias, with bilateral undescended 
testicles and the baby was pronounced to be of the male sex. 



Upon relating this case to Dr. Isidore Cohn of New Orleans he asked why no 
catheter had been inserted into the genital orifice at the time of delivery. The 
answer was simple; it had not been thought of. Realizing, liowever, that cystoscop- 
ing the orifice was very similar to catheterizing the same orifice, permission was 
obtained from the mother to insert a catheter and immediately iirine was obtained. 
Had this examination been made at the time of delivery, the family would have 
been saved the very unpleasant and embarrassing situation in which they were 
placed. 

Tills very simple, but accurate diagpiostic procedure of catheterizing whatever 
orifice that presents itself in abnormal genital formations of the newborn is offered 
in order to ascertain immediately, when the usual methods of examination fail, the 
true sex of the child. 


1640 Arabella Street. 




v 

THE UMBILICAL CORD RELATIVELY SHORTENED BY 
COILING ABOUT THE NECK OF THE FETUS* 

Abner Zehm, M.D., Schofield Barracks, T. H. 

M any cases have been reported in the literature upon this subject. However 
the occurrence of four or more coils of cord about the neck of the fetus is 
rare. McCaffrey, i in his series of 3,000 cases, found three cases with the cord 
about the neck four times. In his series, there were no cases with more than four 
loops of cord about the neck. Konikow^ considered one case with a cord 97 cm. in 
length and coiled about tlie neck of the infant three times of sufficient interest to 
report it. Gossetts reported a ease with five coils of the umbilical cord about the 
neck of tlie fetus. Edgar is mentioned as having had a case with the cord wound 
seven times about the neck causing death of the fetus. There are many more 
cases reported but the incidence of breech presentations reported is rare. For this 
reason, I feel justified in reporting a ease delivered by breech extraction with a 
cord 120 cm. in length coiled about the neck of the fetus six times. 

Mrs. 0. M., multipara in her third pregnancy reported to the prenatal clinic of 
the Station Hospital, Schofield Barracks, T.H., for observation and treatment at the 
end of her sixth month of pregnancy. Blood pressure readings and urine specimens 
were all negative during her prenatal period. Measurements were very adequate. 
Examination at the eighth mouth of pregnancy revealed a breech presentation. 
Tliis position was verified by the x-ray. Several attempts to do exteinal version 
failed in spite of the fact that this patient presented a rather pendulous abdominal 
wall and w'as completely relaxed. History of previous pregnancies was that she had 
kad a breech presentation in her first pregnancy but an external version was suc- 
cessfully performed. The patient rvent through a normal delivery. Second preg- 
nancy was entirely normal with the patient in labor about three hours. 

Patient •was admitted to the hospital in labor at full term at 11:30 A.M. after 
she had been in labor for two hours at home. The fetus -was in the S.L.A. position 
with a complete breech presenting. The fetal heart rate was 14S and of good 
quality. The patient was in good condition but complained that the pains were 
more severe than they had been wdth the two previous deliveries. At 12:00 o’clock 
the patient was given rectal anesthesia. At 2.00 p.m. the membranes ruptured 
spoutaneouslj' and the cervix was fully dilated. The fetal heart rate at this time 
was 156 and of good quality. The breech advanced rather slowly and at 3:00 P.M. 
when the fetal heart rate had accelerated to 164, a foot was drawn down and the 
fetus delivered in the normal manner at 3:15 p.ji. After the umbilicus had passed 
the vulva, an attempt was made to pull the cord down and relieve tension but this 
was impossible. The shoulders and the head were quickly delivered, and the 
umbilical cord 'u’as tightly wound about the neck six times. The child 'U’as rather 
flaccid for a short time but was quickly resuscitated. There ■was no excessive bleeding 
and the placenta delivered spontaneously ten minutes after delivery. The cord 
was of very small diameter, about the size of an ordinary lead pencil, and measured 
126 cm. The circumference of the infant’s neck was 19 cm. ■which, when multiplied 
hj six, gives 114 cm., the total length of the cord utilized by coiling about the 
neck. This amount subtracted from 126 cm., the actual length of the cord, leaves 
only 12 cm. of available cord. This is indeed much too short to allow normal 

Oh.stetricnl Section, Station Hospital. Schoflohl Barrack.-:. Territory of 


923 



924 


AMERICAN JOURNAL OP OBSTETRICS AND GYNECOLOGY 


delivery in tlie average case, and I was very fortunate to have no serious complica- 
tions develop in the deliverj' of this case. There was normal recovery for the 
mother, and the child was in excellent condition when discharged from the hospital. 

Shortness of the umbilical cord was not suspected in this case. However, the 
inability to do external version and the increased pain with uterine contractions 
should have led me to suspect this condition. 

REFERENCES 

(1) McCaffrey, Lawrence L.: Am. J. Obst. & Gynec. 13: 104, 1927. (2) 

Konikow, M. J.: Boston M. & S. J. 77: 560, 1917. (3) Gossett, Walter; Am. J. 

Obst. & Gynec. 13: 783, 1927. 


INCOMPLETE BIPARTITE UTERUS WITH UNILATERAL 
HEMATOCOLPOS AND S ALPINGIT IS.^ 

George L. Carrington, A.M., M.D., Burlington,^ N. C. 

T^HIS ease is reported for two reasons. The first is to call attention to the occasional 

usefulness of the x-ray when it is desired to show both external contour and 
internal arrangement. This can be accomplished as here shown by the aid of an 
opaque substance for internal injection and external application. The second rea- 
son is the interest of the case itself. The only thing that prevented this from 
being a uterus didelphys was a communication for a distance of about a quarter 
of an incli between the two ceiwical canals. There was a double vagina. The left 
was imperforate and filled with blood, constituting a hematocolpos. On the left 
side also, the patient had an acute salpingitis and ovarian abscess. The right 
tube and ovary were normal. It is interesting that the tube on the side of the 
imperforate vagina should have been the one infected. 

0. L. L., white, eighteen years of age, single. Eainey Hospital No. 6887. Ad- 
mitted April 28, 1930. Discharged May 24, 1930. 

The patient applied for treatment because of lower abdominal pain and leu- 
corrhea. Her past history was essentially uninteresting except as it concerned the 
present illness. She had menstruated normally since beginning at the age of four- 
teen years. For one year previous to admission, she had been troubled by leucor- 
rhea. For two months she had had lower abdominal pain and tenderness. 

Physical examination showed a slightly underweight, mildly anemic girl of about 
eighteen years with evident sex appeal. There were slight elevations of tempera- 
ture, pulse, and leucocyte count, and diminution of red cell count and hemoglobin. 
The general physical and laboratory examinations were otherwise essentially nega- 
tive except for the findings in the pelvis and abdomen. 

Pelvic examination revealed a tender mass bound down in the culdesac extend- 
ing to the left. The cervix was normal to inspection and palpation. There was a 
small, soft cystic mass along the left vaginal wall extending the wliole length of 
the vagina. 

May 1, 1930, operation. Preliminary dilatation of the cervix and curettage of 
the uterine cavity were done. The endometrium was hj-pertropliied and bled rather 
freely. 

A lower midline incision was then made in the abdomen. The left fallopian 
tube was acutely inflamed and distended with pus. The left ovary was abscessed. 
Tube and ovary were adherent to the peritoneum in the culdesac. The uterus was 
bicomuate. We removed both tubes, the left ovary, the supravaginal portion of 



CAKRING'J'ON : 


INCOMPLETE BIPARTITE UTERUS 


925 


the uterus and the appendix. As we cut across the cervix, about two ounces of 
old blood oozed up into the pelvis, from the cystic mass that we had described 
along the left vaginal wall at the time of examination but had failed to recognize 
as a hematocolpos. There was an anomalous fibrous cord across the floor of the 
pelvis extending from the cervix backward in the midline to the lower sacrum. 
We peritonealized all raw surfaces and closed the abdomen tight. A smear from 
the left tube showed diplococci, that were not further identified. 

The patient did not stand her operation particularly well, so after closure of 
the abdomen, she was returned to the ward and the vaginal plastic left until six- 



Fig. 1. — Bicornuate uterus with unilateral salpingitis. Uterine cavity injected and sur- 
face of specimen painted with sodium iodide. 

teen days later. At that time under light gas anesthesia, we excised the partition 
between the two vaginas. Examination then showed two ceivices, one opening in 
each vagina. About one-half of an inch from the external os, however, the cervices 
joined and just above this junction there was for a distance of about one-fourth 
inch a communication between the two cervical canals. This had not been recog- 
nized during the preliminary dilatation and curettage of the uterus. This com- 
munication had prevented the formation of a large hematocolpos on the left side 
and at the same time had allowed the development of an acute inflammation in 
the left tube from organisms that gained entrance through the right vagina. 

The patient made a good recovery and has a typical storybook ending of niar- 
rying and living happily. 

Our thanks are due to Dr. B. B. McDade for his interest in making the x-ray plioto- 
ftraph of this specimen of the excised uterus and tubes. 



Society Transactions 


CENTRAL ASSOCIATION OP OBSTETRICIANS AND 
GYNECOLOGISTS 

Fourth Annual jMeeting. Memphis, Tenn. 

SEPTEMBER IS, 16, 17, 19S2 

The following papers were presented: 

A Naegele Pelvis With Coincidental Deformities of Genital Tract and Extremi- 
ties. Dr. J. R. Eeinberger, Memphis, Tenn. (Sec page 834.) 

Endometrial Hyperplasia. Dr. L. E. Burch and Dr. J. C. Burch, Nashville, 
Tenn. (See page 826.) 

A Consideration of the Schneider Modification of the Aschheim-Zondek Test 
as Related to Private Practice. Dr. H. S. Morgan, Lincoln, Neb. (See page 816.) 

The Test of Labor. Dr. L. Rudolph, Chicago, 111. (See page 840.) 

Suppurative Mastitis. Dr. E. ‘A. Johnston, Houston, Tex. 

The Toxic Psychoses of Pregnancy and the Puerperium. Dr. L. S. McGoogan, 
Omaha, Neb. (See page 792.) 

Avitaminosis as a Likely Etiologic Factor in Polyneuronitis Complicating Preg- 
nancy. Dr. R. Luikart, Omaha, Neb. (See page 810.) 

The Importance of the Pulse Rate in Labor. Dr. B. G. Hamilton, Kansas City, 
Mo. 

The Dangerous Multipara. Dr. B. Solomons, Dublin, Ireland. 

Report of a Case of Ablatio Placentae Followed by Sloughing of the Uterus. 
Dr. W. A. Coventry and R. J. Moe, Duluth, Minn. (See page 859.) 

Puerperal Gynecology. Dr. J. L. Bubis, Cleveland, 0. 

Trichomonas Vaginalis (Donnd). Dr. I. F. Stein and Dr. E. J. Cope, Chicago, 
111. (See page 819.) 

The Fallacies of Trichomonas Vaginalis Vaginitis: Streptococci as the Etio- 
logical Agent. Dr. H. C. Hesseltine, Chicago, 111. (Will appear in the July issue.) 

Blood Studies in Pregnancy and the Puerperium. Dr. W. J. Dieckmann and 
Dr. C. Wegner, St. Louis, Mo. (To be published later.) 

Etiology of Prolapse. Dr. E. von Graff, Iowa City, Iowa. (See page 800.) 


926 



INC, OMPLEOJE 

• ^ 6^ 6 ^ ^ <s. are missing# 


In this -volnjae pp 



Al>AlR, Fred L.., Report of a case In which 
a stem pessary had been embed' 
ded for fifteen years in the uterus, 
750 ^ , 

— . Back, G. M., and Long, E. M, J.,_A 
bacteriological study of technics 
for taking vaginal and cervical 
cultures, 551 

Allen, Edward, Abdominal pregnancy 
complicated by eclampsia, 753 

— , The irregularity of the menstrual 
function, 705 

Alsobkook, H. B., Report of a case of 
ovarian fibroid, 009 

Aranow, Harry, An account of a year’s 
service in obstetrics at the Mor- 
risania Hospital, a public institu- 
tion, 420 


B 


Bacon, Charles S.. Prevention and con- 
trol of morbidity and mortality 
from puerperal infection by state 
or municipal supervision and in- 
spcction 194 

Barringer. Emily Hunning, Strauss. 
Hyman, and Crowley, Daniel f.. 
The problem of ‘‘clinical gonor- 
rhea" in the female, 538 
Bates, Gaylord S., Bilateral renal agen- 
esis In the fetus, associated with 
oligohydramnios, 41 

Behney, Charles Augustus, Pelvic sym- 
pathectomy for pain In carcinoma 
of the cervix, 687 

Relson, Maurice O., (with Phaneuf, 
Louis E.), a report of the end- 
results of 554 consecutive hys- 

Bbmis, George Gordon, A clinical study of 
avertin in gynecology and obstet- 
rics, 677 

Bbrcby, James E.. (with Sure, Julius 
H.), Quinine insufflation treat- 
ment of Trichomonas vaginalis, 
preliminary report, 136 
Bercovitz, Z., The pupillary test for the 
diagnosis of pregnancy, based on 
the observation of 382 patients, 
882 

Bbrnstinb, J. B., Further studies in the 
treatment of puerperal septicemia 
and other blood stream infections 
with metaphen, 849 

boley, Henry B., Report of a case of 
velamentous insertion of the cord 
with rupture, and subsequent 
„ death of fetus in uterus, 156 
oOThe, Frederick a.. Hyperthyroidism 
associated with pregnancy, 628 
Brandau, G. M., The respiratory func- 
detached placenta. 95 
BRANDT, Murray L., The mechanism and 


management of the third stage of 
labor, 662 

brewer, John I., and Jones, Harold O.. 
Granulosa cell hyperplasia of the 
ovary, 505 

BROWN, Claude p,, (with Mohler, Rot 
W.), Doderlein’s bacillus in the 
Rnjix-,„„c’'®T^'ddnt of vaginitis. 718 
brunton, James F., (with Morris. Har- 
old L.), Vesicoureteral reflux as 
an etiologic factor in pyelitis of 
^ pregnancy, 414 

ullard e. a.. Pelvic spleen with tor- 
. ®ion of pedicle. 599 


I BURCH, John C., (with Burch, Lucius 

E. ), Endometrial hyperplasia, a 
review of experimental work, 826 

BURCH, Lucius W., and Burch, John C., 
Endometrial hyperplasia, a review 
of experimental work, 826 

Bush, Hubert S., Tuberculosis of the fe- 
male genital tract, 568 

c 

I Carrington, George L., Incomplete bi- 
partite uterus with unilateral 
' hematocolpos and salpingitis, 924 

CARY, W. H., A clinical study of 100 cases 
of developmental and functional 
deficiencies in the female with an- 
alysis of treatment and results, 
335 

CASE, James T., (with Danporth, W. 

CO j Enterouterine fistula, with a 
review of the literature and re- 
port of a case studied radiologi- 
cally, 200 

Castallo, Mario A., Instrument facilitat- 
ing a traumatic palpebral sepava- 
tion in the newborn. 451 

COPE, Elizabeth J., (with Stein, Irving 

F. ), Trichomonas vaginalis 
(Donnd), 819 

Cosgrove, Samuel A., and Waters, Ed- 
WARD C., Injuries to the vagina 
resulting from the Elliott treat- 
ment, 729 

Coventry, W. A., and Mob, Russell J., 
Prolapse of the uterus, 257 

— , AND — , Report of a case of ablatio 
placentae followed by sloughing of 
the uterus, 859 

Crowley, Daniel f., (with Barringer, 
Emily Dunning, and Strauss, 
Hyman). The problem of “clin- 
ical gonorrhea" in tiie female, 538 

Culbertson. Carey, Gauze pad removed 
from the abdomen, 752 

D 

DACK, G. M., (with Adair, Fred L., and 
Long, E. M. J.), A bacteriological 
study of technics for taking vag- 
inal and cervical cultures, 551 

Daichman, Isidore, and Pomerance. 
William, A study of 733 cesarean 
sections, 522 

Danforth, W. C., and Case, James T.. 
Enterouterine fistula, with a re- 
view of the literature and report 
of a case studied radiologically, 
300 

Dannreuther, Walter T., The qualifica- 
tions of the specialist, president’s 
address, 165 

Davidow, David M., (with Yates, H. 
Wellington. Putnam, Eliza- 
beth, and Ellman, Frances), A 
study in correlation of the sedi- 
mentation test, filament-nonfila- 
ment, and the wliite ceil count in 
gynecologj', 203 

Davis, M. Edward, (with Dieckmann. 
William j. ), The volumetric de- 
termination of amniotic fluid with 
Congo red, 623 

Dean, Archie L„ Jr., Injury of the uri- 
narv bladder following irradiation 
of the uterus. 667 

DeCosta, Edwin j., Spontaneous amputa- 
tion of the cervix during labor. 
557 


B23 


‘January, pp. i-ie 4 ; 
<8 : June. 779-926. 


February, pp. 165-316 ; March, 317-464 ; April, 


465-622 : 


May. 


927 


928 


AUTHORS INDEX 


Dembo, Leon H., An analysis of 55 cases 
of hemorrhage in newborn, 587 
Dennen, Edward H., Cyanosis of the 
newborn, case reports showing 
value of x-ray as an aid in diag- 
nosis, 147 

De Sanctis, Nicholas M.. and Diasio, 
J. SANTE, A case of unilateral 
ovarian aplasia and homolateral 
rudimentary fallopian tube associ- 
ated with a normally developed 
uterus, 602 

Diasio, J. Sante, (with De Sanctis, 
Nicholas M. ), A case of unilater- 
al ovarian aplasia and homolat- 
eral rudimentary fallopian tube 
associated with a normally de- 
veloped uterus, 602 

Dieckmann, William j., and Davis, M. 
Edward, The volumetric deter- 
mination of amniotic fluid with 
Congo red, 623 

Dodek, Samuel M., Report of a case of 
ruptured ovarian cyst in the new- 
born, 914 

Dorsett, E. Lee, Placenta acereta, con- 
servative versus radical treatment, 
with a report of three cases,. 274 
Duncan, Cameron, and MacLachlan, 
Glen R., Report of a case of yel- 
low atrophy of the liver in the 
latter part of pregnancy, with re- 
covery, 157 

E 

Eastman, Nicholson J., Spontaneous 
evolution of the fetus in trans- 
verse presentation, 382 
Edeiken, Louis, Small doses of x-ray for 
amenorrhea and sterility, 511 
Edlaiutch, E. S.. (with Samuels, A.). 
A clinical pathologic study of 303 
consecutive abdominal hysterec- 
tomies, 397 

Ellman, Frances, (with tates, H. 
Wellington, Davidow, David M., 

AND PUTNAM, ELIZABETH), A 
study in correlation of the sedi- 
mentation test, fllament-nonflla- 
ment, and the white cell count in 
gynecolog}-, 203 

F 

Falls, Frederick H., Endometritis and 
physometra due to Welch bacillus. 
280 

FisCHMANN, E. W-. A case of leuco- 
plakia of the vulva followed by 
carcinoma developing in the scar 
of the vulvectomy. 309 
Furness, H. Dawson. Report of the re- 
sults after twelve years, in a case 
of ureterovesical anastomosis, 154 

G 

Gabrielianz, Alexander G- Organother- 
apy of mastodynia, 499 
Geist, Samuel H., The viability of frag- 
ments of menstrual endometrium, 
751 

— , and Matus, Morris, Postmenopausal 
bleeding, 388 

Goldberger, M. a.. Kraurosis vulvae. with 
a report of thirteen cases, 58 
— , (WITH Peck, Samuel M.), The treat- 
ment of uterine bleeding with 
snake venom (Ancistrodon pis- 
civorus), 887 

Goldstine, mark T., Aspergillus fumi- 
gatus vaginitis, 756 

Golub, Leib, (with Mann, Bernard, and 
Meranze, David), Aschheim-Zon- 
dek pregnancy test, Friedman 
modification with report of 174 
cases, 723 

Graff, Erwin von, Etiologj' of prolapse, 
800 


Greenhill, j. P., Acute (extragenital) 
Infections in pregnancy, labor, 
and the puerperium, 760 (Collec- 
tive review) 

— , Cystic fibroid weighing forty-seven 
pounds and simulating an ovarian 
cyst, 440 

— Heart-block in pregnant women, 125 
— , Foreign bodies left in the abdomen 
after operation, 231 

H 

Hansmann, G. H., and SCHENKEN, j. R.. 
Endometrioses of lymph nodes, 
572 i 

Harer, W. Benson, Primary carcinoma 
of Bartholin’s gland, 714 
Hatnes, L. W., Uterus duplex, 604 
Hellman, Alfred M., (with Kilroe, 
John Charles), Entrance of lip- 
iodol into ovarian and other veins 
during uterography, 152 
Hennesst, James P., Osteogenesis imper- 
fecta. 590 

Hersh, j., a case of laryngeal diphtheria 
complicating the puerperium, 133 
Hertig, Arthur T., (with Kellogg, Fos- 
ter S.), The relationship between 
exogenous throat streptococci and 
puerperal infections, 213 
Hibbert, G. H., The significance of strep- 
tococus in Trichomonas vaginalis 
vaginitis, 465 

Hirsch, Edwin F., and Jones, Harold 

0. , The behavior of the epitheli- 
um in explants of human endo- 
metrium, 37 

Hofbauer, j.. Epithelial proliferation in 
the cervix uteri during pregnancy 
and its clinical implications, 779 
Holman, Albert W., and Mathieu. Al- 
bert, Blood chemistry studies of 
normal newborn infants, a pre- 
liminary communication, I. Blood 
sugar estimations, 138 
Horine, Ctrus F., Tumors of the round 
ligament, 446 

Hornet, Karen, Psychogenic factors in 
functional female disorders, 694 
Hoyt, W. Fenn, (with Meigs, Joe Vin- 
cent), Rupture of the graafian 
follicle, the corpus luteum and 
small follicle or lutein C5’’sts sim- 
ulating appendicitis, 532 
Htams, Mortimer N., Conization of the 
uterine cervix, 653 

I 

Ingalls, N. AVilliam, Congenital defects 
of the scalp, 861 

IVT, A. C., (with Rudolph, Louis), In- 
ternal rotation of the fetal head 
from the viewpoint of compara- 
tive obstetrics, 74 

J 

Jameson, Edwin M., An analysis of the 
menstrual changes in tuberculous 
women, 22 

Jones, Harold O., (with Brewer, John 

1. ), Granulosa cell hyperplasia of 
the ovary, 505 

— . (with Hirsch, Edwin F.), The be- 
havior of the epithelium in ex- 
plants of human endometrium, 37 

K 

Kaldor, Joseph, Congenital pneumonia of 
the stillborn and the newborn, 113 
Kaplan, Ira I., Radiation therapy in 
gj-necologic malignancy, 368 
Kellogg, Foster S., and Hertig, Arthur 
T., The relationship between ex- 
ogenous throat streptococci and 
puerperal infections, 213 
Kilbourne, Norman J., Varicose veins of 
pregnancy, 104 



AUTHORS INDEX 


929 


laLROE, John Charles, and Hellman, 
Alfred M., Entrance of liplodol 
into ovarian and other veins dur- 
ing uterography, 152 
KING, Arthur G., The Bercovitz test for 
pregnancy, a report of 260 cases, 
99 

King, Jessie E., Menstrual intervals, 583 
Kirchnbr, Walter C. G., Sigmoidouter- 
ine and vesicouterine flstula as a 
complication of childbirth, 241 
Kolischer, G., Some urologic complica- 
tions in the female, 128 
Koster, Harry, On the supports of the 
uterus, 67 

Krohn, Leon, (with Lackner, Julius 
E.), Report of a case of tera- 
toma of the uterus, 735 
Kuhn, Clifford, (with Schauffler, 
Goodrich C.), Information re- 
garding gonorrhea in the immature 
female. 374 


L 

Lackner, Julius E., and Krohn, Leon. 
Report of a case of teratoma of 
the uterus, 735 

Lash, a. P., Puerperal sepsis; B. 

Welchii, fatal types, 288 
Lawrance, J. Stuart, Concerning death 
of fetus in pregnancy, 633 
Leventhal, M. L., Complete placental de- 
tachment with apoplexy of the 
uterus requiring hysterectomy, 748 
Levy, Walter E., and Tripoli, Carl J., 
Gummas of the urinary bladder, 
743 

Lifvendahl, R. a., a case in which sev- 
eral foreign bodies were found in 
the vagina of a feeble-minded 
pseudohermaphrodite, 156 
— , Tubal pregnancy following uterine in- 
semination, 733 

Lintgbn, Charles, A case of ectopia cor- 
dis, 449 

Long, E. M. J., (with Adair, Fred L., 
AND Lack, G. M.), A bacteriologi- 
cal study of technics for taking 
vaginal and cervical cultures, 551 
Lowenburo, Henrietta, (with Mann, 
Bernard) , Submucous myoma 
complicating the puerperlum, A 
review of the literature with the 
report of a case. 443 
Luikart, Ralph, Avitaminosis as a likely 
etiologlc factor in polyneuronitis 
complicating pregnancy, with the 
report of a case, 810 
Lull, Clifiurd B., A survey of cesarean 
sections performed in Philadelphia 
during 1931, 426 


M 

MacICenzib, Pierce, The treatment of as- 
phyxia in the newborn by lung 
inflator for indirect mouth-to- 
mouth breathing, 918 
macLachlan, Glen R., (with Duncan, 
Cameron), Report of a case of 
yellow atrophy of the liver in the 
latter part of pregnancy, with re- 
covery, 157 

AiANN, Bernard, and IwOWenburg, Henri- 
etta, Submucous myoma compli- 
cating the puerperium. A review 
of the literature with the report 
of a case, 443 

. Meranze. David, and Golub, Leib, 
Ascmieim-Zondek pregnancy test, 
Fi'iedman modiflcation with report 
723 

IAson, Lyman W., Hypertrophy of the 
report of two cases, 144 
thieu, Albert, (with Holman, Al- 
bert W.), Blood chemistry studies 
of normal newborn infants, a pre- 
liminary communication, I. Blood 
sugar estimation, 138 


IilATUS, Morris, (with Geist, Samuel 
H.), Postmenopausal bleeding, 388 
Mazzola, Vincent P., and Torrey, Mar- 
cus A., An experimental study of 
the effects of intravenous injec- 
tions of hypertonic glucose solu- 
tion (50 per cent) on the circu- 
lation of the cat, 643 
McGoogan, Leon A., The toxic psychoses 
of pregnancy and the puerperium. 
792 

McKnight, R. B., and Patterson, Reid, 
Ureteronephrectoniy during early 
pregnancy, 141 

McLaughlin, Edward Francis, A specu- 
lum for use in cervical cauteriza- 
tion, 755 

Meigs, Joe Vincent, and Hoyt, W. Fenn, 
Rupture of the graafian follicle, 
the corpus luteum and small fol- 
licle or lutein cysts simulating ap- 
pendicitis, 532 

Mengert, William F., Subacute bacterial 
endocarditis as a complication of 
pregnancy, 121 

Meranze, David, (with Mann, Bernard, 
AND Golub, Leib), Aschheim-Zon- 
dek pregnancj’’ test, Fi'iedman 
modification, with report of 174 
cases, 723 

Miller, James Raglan, Multiple dermoids 
of the ovary, 252 

— , The use of mortality statistics in rat- 
ing maternity service, 577 
Moe, Russell J., (with Coventry, W. 

A.), Prolapse of the uterus, 257 
— AND — , Report of a case of ablatio 
placentae followed by sloughing of 
the uterus, 859 

Moench, G. L., Do sperm morphology and 
biometrics really offer a reliable 
index of fertility? 410 
Mohler, Roy W.. and Brown, Claude P., 
Dfiderlein’s bacillus in the treat- 
ment of vaginitis, 718 
Montgomery, Thaddeus L., Lesions of the 
placental vessels. Their relation- 
ship to the pathology of the pla- 
centa : their effect upon fetal mor- 
bidity and mortality, 320 
Morgan, Harold S., A consideration of 
the Schneider modification of the 
Aschheim-Zondek test as related 
to private practice, 816 
Morris, Harold L., and Brunton, James 
F., Vesicoureteral reflux as an 
etiologic factor in pyelitis of preg- 
nancy, 414 


N 

Nelson, Harry M., Report of a case of 
fibroma of the vulva with sar- 
comatous degeneration, 594 

Neustaedter, Theodore, Report of a case 
of leucokraurosis (kraurosis vul- 
vae) cured by vulvectomy, 601 

Newberger, Charles, Report of a case of 
congenital defect in the dia- 
phragm, 306 

Newell. Quitman U., Injury to ureters 
including accidental ligation dur- 
ing pelvic operations, 220 

P 

Papanicolaou, George N., Epithelial re- 
generation in the uterine glands 
and on the surface of the uterus. 
30 

Patterson, Reid, (with McKnight, R. 
B. ) , ITreteronephrectomv during 
pregnancy, 141 

P AYNE, Waverly R., Rupture of a corpus 
luteum as a cause of acute ab- 
dominal symptoms, case reports. 
150 

Peck. Sajiuel JI., and Goldberger, Mor- 
Ris A., The treatment of uterine 
bleeding with snake venom (An- 
clstrodon piscivorus), 887 



930 


AUTHORS INDEX 


Phaneuf, Louis E., and Belson, Mau- 
rice O., A report of the end-re- 
sults of 554 consecutive hysterec- 
tomies, 262 

Plaut, Alfred, Ovarian struma : a 
morphologic, pharmacologic, and 
biologic examination, 351 

PojiERANCE, William, (with Daichman, 
Isidore), A study of 733 cesarean 
sections, 522 

Putnam, Elizabeth, (with Yates, H. 
Wellington, Davidow, David M., 
AND Ellman, Prances), A study 
in correlation of the sedimenta- 
tion test, fllament-nonfllament, 
and the white cell count in gyne- 
cology, 203 


R 

Randall, Lawrence M., Hysterostomat- 
omy, 873 

RAUDENBUSH, JAMES S., Placenta previa 
with twin pregnancy, 752 
Reeves, E. Edwin, Retzius space abscess 
following laparotomy, 897 
Reinberger, James R., a Naegele pelvis 
with coincidental deformities of 
genital tract and extremities, 834 
Retcraft, J. L., And Seecof, David. 
Chronic hypertrophic vulvitis (el- 
ephantiasis) complicating labor, 
608 

RiGDON, R. H., Adenomyoma (adenomy- 
osis of Frankl) of the uterus with 
tuberculous infection, 902 
Ronsheim, Joshua, Diabetes and preg- 
nancy, 710 

Rosenfeld, Samuel S., pregnancy and la- 
bor subsequent to abruptio pla- 
centae and uteroplacental apo- 
plexy, 911 

Rudolph, Louis, The test of labor, 840 
— , AND IvT, A. C., Internal rotation of 
the fetal head from the viewpoint 
of comparative obstetrics, 74 
Russell, Hollis K., Lymphatic leucemia 
and pregnancy, 493 


S 

Samuels, A., and Edlavitch, E. S., A 
clinical pathologic study of 303 
consecutive abdominal hysterecto- 
mies, 397 

Sarma, P. J., Report of a case of ovarian 
embryoma, 51 

Schauffler, Goodrich C., and Kuhn. 

Clifford, Information regarding 
gonorrhea in the immature fe- 
male, 374 

Schenken, j. R., (With Hansmann, G. 
H.), Endometrioses of lymph 
nodes, 572 

Schmitz, Henry, The technic of radia- 
tion therapy in uterine carcin- 
omas, 10 

Schochet, Sydney S., and Lackner, Ju- 
lius E., An instrument to outline 
the Pfannenstiel incision, 155 

Scofield, Paul D.. True sarcomatous 
change in a uterine fibroid, 920 

Sears, Nathan P., Granuloma of the vag- 
inal vault. 906 

— , The fascia surounding the vagina, its 
origin and arrangement, 484 

Seecof, David, (with Reycraft, J. L.), 
Chronic hypertrophic vulvitis (el- 
ephantiasis) complicating labor. 
608 

Sevringhaus. Elmer L., The use of fol- 
liculin in involutional state, 361 

Siegel, Isadore A., Abruptio placentae, 
894 

Skeel, a. j.. New methods of study ap- 
plied to maternal mortalities in 
the hospital. 187 

SOLOMONS. Bethel, Some phases of the 
toxemias of pregnancy, 172 


Spielman, Frank, Tubular adenoma (ar- 
rhenoblastoma) of the ovary, 517 

Stein, Irving F., and Cope, Elizabeth 
J., Trichomonas vaginalis 
(Donnd), 819 

Strauss, Hyman, (with Barringer, Em- 
ily Dunning, and Crowley, Dan- 
iel F. ), The problem of “clinical 
gonorrhea” in the female, 538 

Styron, Norma C., (with Williams, An- 
na W. ), Specific bacterial cervici- 
tis, 547 

Sure, Julius H., and Bercey, James E.. 
Quinine insufflation treatment of 
Trichomonas vaginalis, prelimi- 
nary report, 136 

T 

Torrey, Marcus A., (with Mazzola, Vin- 
cent P.), An experimental study 
of the effects of intravenous in- 
jections of hypertonic glucose solu- 
tion (50 per cent) on the circula- 
tion of the cat. 643 

Tripoli, Carl j., (with Levy, Walter 
E.), Gummas of the urinary blad- 
der, 743 

U 

Urner, John A., The use of adrenalin in 
the treatment of acute inversion 
of the puerperal uterus, with re- 
port of a case, 131 

V 

Van Del, D. T., The oral administration 
of sodium amytal in labor. A 
clinical analysis of two hundred 
fifteen cases, 564 

Vesell, Morton, a modification of the 
Friedman pregnancy test. 909 

Vineberg, Hiram N., Report of a case 
of myomectomy for an interstitial 
fibroid complicated by a very 
early pregnancy, 746 

W 

Ward, George Gray, The complications 
of radium therapy in gj-necologj', 
1 

Washburn, Newell R.. Extensive de- 
struction of genital tract, 606 

Waters, Edward (j., (with CosGROvm, 
Samuel a.) , Injuries to the vagina 
resulting from the Elliott treat- 
ment, 729 

Weber, Henry W., Perforation of a fibro- 
myomatous uterus, following ver- 
sion. 597 

Wechsler. B. B., Tubal pregnancy at term. 
600 

AVHITELOW, Maurice J., Tubal contrac- 
tions in relation to the estrus 
cycle as determined by uterotubal 
insufflation, 475 

AVilliams. Anna ^ V ., and Styron, 
Norma C., Specific bacterial cervi- 
citis, 547 

AVitherspoon, j. Thornwell. a simple 
procedure of ascertaining the sex 
of newborn, where the diagnosis is 
difficult due to genital abnormali- 
ties, 921 

T 

A'ates, H. Wellington, Davidow, David 
M., Putnam, Elizabeth, and Ell- 
man, Frances. A study in correla- 
tion of the sedimentation test, flla- 
ment-nonfllament, and the white 
cell count in gj'necologj', 203 

Z 

Zehm, Abner, The umbilical cord rela- 
tively shortened by coiling about 
the neck of the fetus. 923 



SUBJECT INDEX^^ 


A 


Abdomen, foreign bodies left in. after op- 
eration, (Greenhlll). 231 
gauze pad removed from, (Culbertson), 


752 


Abdominal hysterectomies, clinical patho- 
logic study of 303 consecutive. 
(Samuels and Edlavitch), 397 
pregnancy complicated by eclampsia. 
(Allen), 753 

Ablatio placentae followed by sloughing 
of uterus, report of case, (Co- 
ventry and Moe), 859 


Abortion, artificial, indications and meth- 
ods of, (Winter), 4C3 (Book re- 
view) 

puerperal sepsis. Bacillus welchii, fatal 
types, (Lash), 28S 
Abruptio placentae, (Siegel). S94 

and uteroplacental apoplexy, preg- 
nancy and labor subsequent to, 
(Rosenfeld), 911 


Abscess In Retzius space following lapa- 
rotomy, (Reeves), 897 

Absti-acts, eclampsia, 773 
endometrium, 101 

miscellaneous, 98, 159, 162, 193, 401, 550. 
582. 503. 017 

sterility and sterilization, 312 

Acid base balance in pregnancy, regula- 
tory mechanism of, (Anselmino), 
450 (Book review) 

Acute (extragenital) infections in preg- 
nancy, labor, and puerperium, 
(Greenhlll), 700 (Collective re- 
view) 

Adenoma, tubular, (arrhenoblastoma) of 
ovary, (Spielman), 517 
testicular, (Popoff), 017 (Abst.) 

Adenomyoma (adenomyosis of Frankl) of 
uterus with tuberculous infec- 
tion, (Rigdon), 902 

Adrenalin, use of, in treatment of acute 
Inversion of puerperal uterus, 
(Urner). 131 

Amenorrhea and sterility, small doses of 
x-ray for, (Edeikon). 511 

American Association of Obstetricians. 

Gynecologists and Abdominal 
Surgeons, transactions of, 310 
Board of Obstetrics and Gynecology. 
104. 310, 404, 013, 778 
diplomates of, 014 

Amniotic fluid, volumetric determination 
of, with Congo red, (Dieckmann 
and Davis), 023 

-Vnastomosis ureterovesical, results after 
twelve years in case of, (Fur- 
niss), 154 


•Vnesthesia, epidural, in obstetrics, (Henry 
and Jaur), 021 (Abst.) 
local, for gynecologic abdominal opera- 
tions, simpler, improved method 
of. (Prigyesi), 018 (Abst.) 
prolonged, m obstetrics, (Aburel). 
021 (Abst.) 

lumbar, (Mayer). 582 (Abst.) 


Anesthesia — Cont’d 

spinal, and chloroform administered at 
same time, dangers of, (Gari- 
puy), 020 (Abst.) 

Animals, hormonal sterilization in, (Men- 
clelshtam and Tschaikovsky), 
315 (Abst.) 

sterilization of, without use of hor- 
m o n e s, (Tschaikowsky), 310 
(Abst.) 

Anthrax in pregnancy, labor and puer- 
perium, (Greenhlll), 772 (Col- 
lective review) 

Appendicitis in etiology of female steril- 
ity, role of, (Rubin), 312 (Abst.) 
rupture of graafian follicle, corpus lu- 
teum and small follicle or lutein 
cysts simulating, (Meigs and 
Hoyt), 532 

Arrhenoblastoma, tubular adenoma of 
ovary, (Spielman), 517 

Aschheim-Zondek pregnancy test, Fried- 
man modification, (Mann et ah), 
723 

Schneider modification of, as re- 
lated to private practice, con- 
sideration of, (Morgan), 816 

Aspergillus fumigatus vaginitis, (Gold- 
stine), 756 

Asphyxia in newborn, treatment of, by 
lung inflator for indirect mouth- 
to-mouth breathing, (MacKen- 
zie), 918 

Atmospheric changes on incidence of 
eclampsia, effect of, (Konrad), 
774 (Abst.) 

Avertin in gynecology and obstetrics, clin- 
ical study of, (Bemis), 077 

Avitaminosis as likely etiologic factor 
in polyneuronitis complicating 
pregnancy, with report of case. 
(Luikart), 810 

B 

Bacillus, AVelch, endometritis and physo- 
metra due to, (Falls). 280 
welchii in puerperal sepsis, fatal types. 
(Lash), 2SS 

Bacterial cervicitis, specific, (William.s 
and Styron). 547 

Bartholin’s gland, primaiy carcinoma of. 
(Harer), 714 

Bercovitz test for pregnancy, (King). 99 

Bilateral renal agenesis of fetus associ- 
ated with oligohydramnios, 
(Bates), 41 

Biometrical studies of head lengths of 
human spermatozoa, (Moenoh 
and Holt), 313 (Abst.) 

Biometrics, sperm morphology and, do 
they really offer reliable index 
of fertility, (Moench), 410 

Bladder, urinary, gummas of, (Levy and 
Tripoli). 743 

injury of. following irradiation of 
uterus. (Dean). 007 

Bleeding, postmenopausal, (Geist and 
Matus), 3SS 

uterine, treatment of, witli snake venom 
(Ancistrodon piscivorus), (Peck 
and Goldbergei'), SS7 


‘.Tanuary. 1-ldl; February 
.Tune. 779-920. 


10.5-310; 


March, 317-404 ; 


.•\pril. 405-022; ilay, 023-77.8; 


031 


932 


SUBJECT INDEX 


Blood chemistry studies of normal new- 
born infants, (Holman and Ma- 
thieu), 138 

stream Infection, treatment of, with 
metaphen, (Bernstine), 849 

Body, wisdom of, (Cannon), 461 (Book 
review) 

Bone formation, non-teratomatous, in 
ovary (Settergren), 617 (Abst.) 

Book reviews, 453 

Books received, 622 

Bradycardia, torsion of ovarian cyst with, 
(Matters), 193 (Abst.) 

Breast, mastodynia, organotherapy in, 
(Gabrielianz), 499 

plastic operations on, (Glksmer), 462 
(Book review) 

Breathing, indirect mouth-to-mouth, lung 
inflator for, in treatment of as- 
phjTcia in newborn, (Mac- 
Kenzie), 918 

Brooklyn Gynecological Society, 160, 611 


C 

Carbon dioxide, influence of, on frequency 
of fetal heart rate, (Rech), 620 
(Abst.) 

Carcinoma of cervix, pain in, pelvic sym- 
pathectomy for, (Behney), 687 
primarj', of Bartholin’s gland, (Harer), 
714 

uterine, radiation therapy in, technic 
of, (Schmitz), 10 

Cauterization, cervdcal, speculum for use 
in, (McLaughlin), 755 

Central Association of Obstetricians and 
Gynecologists, 926 

Cervical and vaginal cultures, technics 
for taking, bacteriologic study 
of, (Adair et al.), 551 
cauterization, speculum for use in, (Mc- 
Laughlin), 755 

Cervicitis, bacterial, specific, (Williams 
and Styron), 547 

Cervix, carcinoma of, pain in, pelvic 
sympathectomy for, (Behney), 
687 

spontaneous amputation of, during la- 
bor, (DeCosta), 557 

uteri, epithelial proliferation in, during 
pregnancy, and its clinical im- 
plications, (Hofbauer), 779 
uterine, conization of, (Hyams), 653 

Cesarean sections performed in Phila- 
delphia during 1931, survey of, 
(Lull), 426 

study of 733, (Daichman and Pom- 
erance), 522 

Chicago Gynecological Society, 160, 311, 
611, 758, 759 

Chickenpox in pregnancy, labor and puer- 
perium, (Greenhill), 768 (Collec- 
tive review) 

Childbirth, sigmoidouterine and vesico- 
uterine fistula complicating, 
(Kirchner), 241 

Chloroform and spinal anesthesia admin- 
istered at same time, dangers 
of, (Garipuy), 620 (Abst.) 

Chorea, in pregnancy, labor and puer- 
perium, (Greenhill), 764 (Col- 
lective review) 

Circulation of cat, effects of intravenous 
injections of hypertonic glucose 
solution (50 per cent) on, (Maz- 
zola and Torrey), 043 

Clitoris, hypertrophy of, (Mason), 144 

Collective review, acute (extragenital) in- 
fections in pregnancy, labor and 
puerperium, (Greenhill), 760 
(Collective review) 


Congenital defects of scalp, (Ingalls), 861 
Congo red, volumetric determination of 
amniotic fluid with, (Dieckmann 
and Davis), 623 

Conization of uterine cervix, (Hyams). 
653 

Contractions, tubal, in relation to estrus 
cycle as determined by utero- 
tubal insufflation, (Whitelaw), 
475 

Cord, umbilical, relatively shortened by 
coiling about neck of fetus, 
(Zehm), 923 

velamentous Insertion of, with rupture, 
and subsequent death of fetus 
in utero, (Boley), 156 
Corpus luteum, graafian follicle, and small 
follicle or lutein cysts, rupture 
of, simulating appendicitis, 
(Meigs and Hoyt). 532 
rupture of, as cause of acute abdom- 
inal symptoms, (Payne), 150 
Correspondence, 611 

Count, filament-nonfllament and white 
cell, sedimentation test and, in 
gynecology, (Yates et al.). 203 
Crural hernia, rudimentary bicornate 
uterus in, (Arenas). 622 (Abst.) 
Cultures, vaginal and cervical, technics 
for taking, bacteriologic study 
of, (Adair et al.), 551 
Cyanosis of newborn, (Dennen), 147 
Cyst, ovarian, morphologic, pharmaco- 
logic, and biologic examination, 
(Plant), 351 

ruptured, in newborn, (Dodek), 914 
torsion of, with bradycardia, (Mat- 
ters). 193 (Abst.) 

Cystic fibroid weighing forty-seven pounds 
and simulating ovarian cyst, 
(Greenhill), 440 

Cysts, blood, rupture of. simulating acute 
appendicitis, (Boggan and Wrig- 
ley), 98 (Abst.) 

D 

Death of fetus in pregnancy, (Lawrance), 
033 

Der geburtshilfiich-gynaekologische Sacli- 
verstiindige, (Hiissy), 457 (Book 
review) 

Dermoids, multiple, of ovary, (Miller), 
252 

Diabetes and pregnancy, (Ronsheim), 710 
Diaphragm, defect, congenital, (Newberg- 
er), 306 

Diphtheria in pregnancy, labor and puer- 
perium, (Greenhill), 764 (Col- 
lective review) 

larjmgeal, complicating puerperium, 
(Hersh), 133 

Diplomates, American Board of Obstetrics 
and Gynecology. 614 

Doderleln’s bacillus in treatment of vag- 
initis, (Mohler and Brown), 718 
Dystocia from hysterocele in case of 
double uterus, (Schockaert), 021 
(Abst.) 

E 

Eclampsia, (Klaften), 776 (Abst.) 

abdominal pregnancy complicated by, 
(Allen), 753 

and allied toxemias, examinations of 
renal function in, (Olsen), 773 
(Abst.) 

and preeclampsia, prophylaxis and 
treatment of, (Seitz), 774 
(Abst.) 

atmospheric changes on incidence of, ef- 
fect of. (Konrad), 774 (Abst.) 

700 cases of, (Koteljnikow). 777 (Abst.) 



SUBJECT INDEX 


933 


Eclampsia— Cont’d 

causation of, (Theobald), 774 (Abst.) 
In Chinese patient, (King), 777 (Abst.) 
in Saxony in last ten years, (Kuestner), 
776 (Abst.) 

intestinal origin of, (Brown). 774 
(Abst.) 

prevention and treatment of. on basis 
of 111 observations, (Rissmann), 

775 (Abst.) 

recurrent, (Schmechel), 775 (Abst.) 
retina, detachment of, in, (Klaften), 

776 (Abst.) 

treatment of, (Mueller), 791 (Abst.) 
at Stockton Sud Maternity Hospital 
from 1911 to 192S, ((Jyllen- 
svard), 833 (Abst.) 
at Gothenburg Maternity from 1918 
to 1928, (Thulin), 770 (Abst.) 
Eclamptic and preeclamptic women, late 
results in cases of, (Kobes), 775 
(Abst.) 

Ectopia cordis, case of, (Lintgen), 449 
Elephantiasis, chronic hypertrophic vul- 
vitis complicating labor, (Rey- 
craft and Seecof), 608 
Elliott treatment, injuries to vagina re- 
sulting from, (Cosgrove and 
Waters), 729 


Embryoma, ovarian, (Sarma), 51 


Encephalitis lethargica in pregnancy, la- 
bor and puerperium, (Green- 
hill), 70S (Collective review) 

Endocarditis, subacute bacterial, as com- 
plication of pregnancy, (Men- 
gert), 121 

Endocrine disorders, differential diag- 
nosis of, (Rowe), 453 (Book re- 
view) 

medicine, (Engelbach), 454 (Book re- 
view) 

Endocrinology, clinical, of female, (Mazer 
and Goldstein), 453 (Book re- 
view) 

Handbuch der Inneren Sekretion, 
(Hirsch), 455 (Book review) 

Endometrial hyperplasia, (Burch and 
Burch) , 820 (Burch and Cun- 
ningham), 161 (Abst.) 

Endometrioses of lymph nodes, (Hans- 
mann and Schenken), 572 

Endometritis and physometra due to 
Welch bacillus. (Falls), 280 
tuberculous, (Reinhart and Moore), 162 
(Abst.) 

Endometrium, etiology of hyperplasia of, 
(Hofbauer), 161 (Abst.) 
glandular hyperplasia of, clinical man- 
ifestations of, (Adler), 162 
(Abst.) 

human, explants of, behavior of epithe- 
lium in, (Hirsch and Jones), 37 
menstrual, viability of fragments of, 
(Geist). 751 

Enterouterine fistula with review of lit- 
erature and report of case stud- 
ios radiologically, (Danforth 
and Case), 300 

Epidural anesthesia in obstetrics, (Henrv 
and Jaur), 021 (Abst.) 

Epithelial proliferation in cervix uteri 
during pregnancy and its clin- 
ical implications, (Hofbauer), 
779 


Epithelium regeneration in uterine glanc 
and on surface of uterus, (Pai 
anicolaou), 30 

behavior of, in explants of human endi 
metrlum. (Hirsch and Jones), I 
Erysipelas in pregnancy, labor and pue 
perium, (Greenhill), 705 (Co 
lective review) 

Estrus cycle, tubal contractions in reh 
tlon to, as determined bv uteri 
tubal Insufllation. (Wliltelaw 
4(5 


Eventration of intestines in postoperative 
rupture of abdominal wound, 
(Gerich), 619 (Abst.) 
Examination of sterile couples, methods 
of, (Moench), 312 (Abst.) 


F 

Fallopian tube, homolateral rudimentary, 
unilateral ovarian aplasia and, 
associated with normally de- 
veloped uterus, case of, (De 
Sanctis and Diasio), 602 
reversible sterilization of female by 
crushing, (Naujoks), 315 (Abst.) 
restorative surgery of, methods and 
results of, (Serdukoff), 313 
(Abst.) 

Fascia surrounding vagina, origin and ar- 
rangement, (Sears). 484 

Female, developmental and functional de- 
ficiencies in, clinical study of 
100 cases of, with analysis of 
treatment and results, (Cary), 
335 

disorders, functional, psychogenic fac- 
tors in, (Homey), 694 
genital tract, (Moulonguet), 460 (Book 
review) 

tuberculosis of, (Bush), 568 
immature, gonorrhea in, information re- 
garding, (Schaufiler and ICuhn), 
374 

pelvic viscera, prolapse, (Roberts), 460 
(Book review) 

sterility, r61e of appendicitis in etiology 
of. (Rubin), 312 (Abst.) 
urologic complications in, (Kolischer), 
128 

Fertility, do sperm morphology and bio- 
metrics really offer reliable in- 
dex of fertility, (Moench), 410 

Petal distress, early diagnosis of, in preg- 
nancy, (Lawrance), 638 
head, internal rotation of. from view- 
point of comparative obstetrics. 
(Rudolph and Ivy). 74 
heart rate, influence of carbon dioxide 
on frequency of, (Rech), 620 
(Abst.) 

starvation, (Lawrance), 033 

Fetus, bilateral renal agenesis in. asso- 
ciated with oligohydramnios, 
(Bates), 41 

death of. in pregnancy, (Lawrance), 
633 

in uterus, velamentous insertion of 
cord with rupture, and, (Boley), 
150 

spontaneous evolution of, in transverse 
presentation. (Eastman). 382 
umbilical cord relatively shortened by 
coiling about neck of, (Zehm), 
923 

Fibroid, cs'stic, weighing forty-seven 
pounds and simulating ovarian 
cyst, (Greenhill). 440 
interstitial, myomectomy for, complicat- 
ed by very early pregnancy. 
(Vineberg), 740 

ovarian, report of case, (Alsobrook), 
009 

uterine, true sarcomatous change in. 
(Scofield), 920 

Fibroma of vulva with sarcomatous de- 
generation, report of case, (Nel- 
son), 594 

Fllament-nonfilament and white cell 
count, sedimentation test and 
in gj-necologj', (Yates et al.), 
203 

Fistula, enterouterine, with review of lit- 
erature and report of case stud- 
ied radiologically, (Danforth 
and Case). 300 



934 


SUBJECT INDEX 


Fistula — Cont’d 

sigmoidouterine and vesicouterine, com- 
plicating childbirth, (Kirchner), 
241 

Fistulas of, urinary tract, causes and 
treatment of, with special ref- 
erence to method of four cat- 
gut layers, (Apajalahtl), CIS 
(Abst.) 

Fluid, amniotic, volumetric determination 
of, with Congo red, (Dieckmann 
and Davis) , G23 

Folliculin, use of, in involutional states, 
(Sevrlnghaus), 3G1 

Foreign bodies left in abdomen after op- 
eration. (Greenhill), 231 

Friedman modification of Aschheim-Zon- 
dek pregnancy test, (Mann et 
ah), 723 

pregnancy test, modification of, (Ve- 
sell), 909 

Functional female disorders, ps 3 ’chogenic 
factors in, (Homey), G94 

G 

Gauze pad removed from abdomen, (Cul- 
bertson), 752 

Genital abnormalities, simple procedure 
of ascertaining sex of newborn, 
where diagnosis is difficult due 
to, (Witherspoon), 921 
tract and extremities, deformit'es of. 
Naegele pelvis with coincidental. 
(Reinberger), 834 

extensive destruction of, (Washburn), 
COG 

female. (Moulonguet), 4G0 (Book re- 
view) 

tuberculosis of, (Bush). 5GS 
tuberculosis in women, (Daniel), 4G0 
(Book review) 

Gland, Bartholin’s, primary cai’cinoma of, 
(Harer), 714 

Glands, uterine, epithelial regeneration in. 

and on surface of uterus, (Pap- 
anicolaou). 30 

Glucose solution (50 per cent), hypertonic, 
effects of intravenous injections 
of, on circulation of cat, (Maz- 
zola and Torrey), G43 

Gonorrhea, clinical, in female, problem of. 
(Harringer et ah). 538 
in immature female, information re- 
garding, (Shauflier and Kuhn). 
374 

Graafian follicle, corpus luteum and small 
follicle or lutein cj’sts, rupture 
of, simulating appendicitis. 
(Meigs and Hoj’t), 532 

Granuloma of vaginal vault, (Sears), 90G 

Granulosa cell hyperplasia of ovary, 
(Brewer and Jones), 505 

Graves, Wiliam Phillips, in memorlam. 
317 

obituarj- notice, 311 

Gummas of urinarj' bladder, (Levy and 
Tripoli), 743 

Gynecologic abdominal operations, local 
anestiresia for', simpler Improved 
method of, (Frigj'esl), GIS 
(Abst.) 

malignancy, radiation therapy in, (Kap- 
lan). 3GS 

surge 2 *r', conservative, (Bell), G19 
■ (Abst.) 

Gvnecology. adenomyoma (adenomj-osis 
of Frankl) of uterus with tu- 
berculous Infection, (Rigdon), 
902 

anesthesia. lumbar, (Jlaj'er), 5S2 
(Abst.) 

Aspergillus fumigatus vaginitis, (Gold- 
stine), 756 


Gj'necology — Cont’d 

avertln in. clinical studj' of, (Bemls), 
G77 

cervicitis, bacterial, specific. (Williams 
and Styron), 547 

clitoris, hypertrophy of, (Mason), 144 
complete placental detachment with ap- 
poplexj' of uterus requiring hj's- 
terectomj% (Leventhal), 748 
conization of uterine cervix, (Hj-ams), 
G53 

corpus luteum, rupture of, as cause of 
acute abdominal symptoms. 
(Paj'ne), 150 

cj'stic fibroid, weighing fortj’-seven 
pounds and simulating ovarian 
cyst, (Greenhill), 440 
deficiencies, developmental and func- 
tional in female, clinical studj- 
of 100 cases of, with analj'sis 
of treatment and results. 
(Cary). 335 

endometrial hj^perplasia, (Burch and 
Burch). S2G 

endometrioses of Ij’mph nodes. (Hans- 
mann and Schenken), 572 
endometritis and phj’someti'a due to 
Welch bacillus. (Falls), 280 
enterouterine fistula with review of lit- 
erature and report of case stud- 
ied radiologicallj", (Danforth 
and Case), 300 

fascia surrounding vagina, origin and 
arrangement, (Sears), 484 
female genital tract. (Moulonguet), 400 
(Book review) 

fibroma of vulva with sarcomatous de- 
generation, report of case, (Nel- 
son), 594 

for nurses, sj’llabus of lectures on. 

(Committee of American Gvne- 
cological Societj’), 4G1 (Book 
review) 

foreign bodies found in vagina of feeble- 
minded pseudohermaphi’odite. 
(Lifvendahl), 15G 

gauze pad removed from abdomen, (Cul- 
bertson). 752 

genital tract extensive destruction of. 
(Washburn), COG 

tuberculosis in women, (Daniel). 460 
(Book review) 

gonorrhea,, cl'n'cah in female, nroblem 
of, (Barringer et ah). 538 
in immature female, informat'on re- 
garding, (Schauffler and Kuhn). 
374 

granuloma of vaginal vault, (Sears). 
906 

gummas of uvinarv bladder, (Lew and 
Tripoli). 743 

hj'sterectom’es. abdominal. clinical 
pathologic studj^ of 3"3 consec- 
utive, (Samuels and Edlavitch). 
397 

report of end-results of 554 consecu- 
tive. (Phaneuf and Belsonl 262 
injuries to vagina resulting from Ell’ott 
treatment, (Cosgrove and Wa- 
ters), 729 

injurj' of urinary bladder following ir- 
radiation of uterus. (Dean), 067 
irregularity of menstrual function, (Al- 
len). 705 

kraurosis vulvae, (Goldberger), 5S 
leucokraurosis (Kraurosis vulvae) cured 
bv \-ulvectomy, report of case. 
(Neustaedter). 601 

leucoplakia of vulva followed b.v car- 
cinoma developing in scar of 
vulvectomy'. (Fischmann). 300 
lipiodol, entrance of. into ovarian and 
other veins during uterogr.aphy. 
(Kilroe and Heilman). 1.52 
mastodynia. org.anotherapj' of (Gabriel- 
ianz), 499 

menstrual changes in tuberculous wom- 
en. analysis of. (.Tameson). 22 



SUBJECT INDEX 


935 


Gynecology — Cont’d 

multiple dermoids of ovarj'. (Miller), 
252 

Naegele pelvis with coincidental de- 
formities of genital tract and 
extremities, (Reinberger), S34 
obstetrics and, recent advances in. 

(Bourne and Williams), 450 
(Book review) 

operative, diminution of pain in, 
(Stalmke), 193 (Abst.) 
ovarian fibroid, report of case, (Also- 
brook), G09 

struma, morphologic, pharmacologic, 
and biologic examination, 
(Plant), 351 

ovary, bone formation, non-teratomat- 
ous, in, (Settergren), 017 
(Abst.) 

granulosa cell hyperplasia of. (Brew- 
er and Jones), 505 

testicular tubular adenoma of, (Pop- 
off). 017 

tubular adenoma (arrhenoblastoma) 
of, (Splelman), 517 

pelvic sympathectomy for pain in car- 
cinoma of cervix, (Behney), CS7 
Pfannenstiel Incision, instrument to out- 
line, (Schochet and Lackner), 
155 

Physikalische Therapie der Frauen- 
krankhelten, (Gdl). 459 (Book 
review) 

postmenopausal bleeding, (Geist and 
Matus), 3S8 

practical medical series. (Greenhill), 
455 (Book review) 

primary carcinoma of Bartholin’s gland. 
(Harer), 714 

prolapse, etiology of, (Graff), SOO 

of female pelvic viscera, (Roberts), 
400 (Book review) 

of uterus, (Coventry and Moe). 257 
psychogenic factors in functional fe- 
male disorders, (Homey), 094 
puerperal, (Bubis), 020 (Abst.) 
quinine insufllation treatment of Tricho- 
monas vaginalis, (Sure and Ber- 
cey), 130 

radiation therapy in uterine carcinomas, 
technic of, (Schmitz). 10 
radium therapy in, complications of, 
(Ward). 1 

Retzius space abscess following laparot- 
omy, (Reeves), S97 
rupture of graafian follicle, corpus lu- 
teum and small follicle or lu- 
tein cysts simulating appendi- 
citis, (Meigs and Hoyt). 532 
■sedimentation test, fllament-nonfllament 
and white cell count in, (Yates 
et al.), 203 

speculum for use in cervical cauteriza- 
tion. (McLaughlin). 755 
spleen, pelvic, with torsion of pedicle. 
(Bullard), 599 

stem pessary embedded in uterus for 
fifteen years, (Adair). 750 
submucous myoma complicating pucr- 
perium, (Mann and Lowenburg). 


synopsis of, (Crossen), 400 (Book re 
view) 

teratoma of uterus, report of cas 
(Lackner and Krohn), 735 
torsion of ovarian evst with brady 
, cardia, (Matters). 193 (Abst.) 
Tncliomonas vaginalis (Donnd), (Steii 
and Cope), S19 

quinine insuillation treatment of 
(Sure and Bercev), 130 
vaginitis, sign’fiejince of strepto 
coccus In. (Hibbert), 405 
tubal pregnancy following uterine in 
semination, (Lifvendahl). 733 
tuberculosis of female genital tract 
(Bush), 50S 


Gynecology — Cont’d 

tumors of round ligament, (Horine), 
440 

unilateral ovarian aplasia and homo- 
lateral rudimenta^ fallopian 
tube associated with normally 
developed uterus, case of, (Do 
Sanctis and Diasio), 002 
ureter, lesions of pelvic, produced dur- 
ing course of gynecologic inter- 
ventions, (Vincent), 618 (Abst.) 
ureterovesical anastomosis results after 
twelve years, (Purniss), 154 
ureters, injury to, including accidental 
ligation during pelvic opera- 
tions, (Newell). 220 
urinary tract fistulas, causes and treat- 
ment of, with special reference 
to method of four catgut layers, 
(Apajalahti), 018 (Abst.) 
urologic complications in female, (Kol- 
ischer). 128 

uterine bleeding, treatment of, with 
snake venom (Anc’strodon pis- 
civorua). (Peck and Goldberg- 
er), 887 

uterus duplex, (Haynes), C04 
incomplete bip.artite, with unilateral 
hematocolpos and salpingitis. 
(Carrington), 924 

rudimentary bicornate, in right crural 
hernia, (Arenas). 622 (Abst.) 
vaginal and cervical cultures, technics 
for taking, bacteriologic study 
of, (Adair et al.). 551 
vaginitis, Dbderlein’s bacillus In treat- 
ment of, (Mohler and Brown), 
718 

vulvitis, chronic hypertrophic (elephan- 
tiasis), complicating labor, 
(Reycraft and Seecof), 004 
x-ray for amenorrhea and sterilitv, 
small doses of, (Edeikon), 511 


H 

Handbuch der inneren Secretion, (Hirsch). 
455 (Boole review) 

Head, fetal, internal rotation of. from 
viewpoint of comparative ob- 
stetrics, (Rudolph and Ivv), 74 

Heart-block in pregnant women, (Green- 
hill), 125 

Hematocolpos, unilateral, and salpingitis. 

incomplete bipai’tite uterus with. 
(Carrington), 924 

Hemorrhage in new'born, analysis of 55 
cases, (Dembo), 587 

Hormonal sterilization of animals, (Man- 
delshtam and Tschaikovsky). 
315 (Abst.) 

question of, (Horneffer), 315 (Abst.) 

Hormones, sterilization of anmials with- 
out use of, (Tschaikowsky). 310 
(Abst.) 

Hospital, maternal mortalities in, new 
methods of study applied to. 
(Skeel). 187 

Human endometrium, expl.ants of. be- 
havior of epithelium in, (Hirsch 
and Jones), 37 

sterilization, historj' of sexual steriliza- 
t’'on movement, (Landman). 401 
(Book review) 

Hygiene of marriage, (Everett), 402 (Book 
review) 

Hyperplasia, endometrial, (Burch and 
Burch), 820: (Burch and Cun- 
ningljam). 101 (xVbst.) 
glandular, of endometrium, clinical 
manifestations of, (Adler). 102 
(Abst.) 

Hyperthyroidism associated with preg- 
nanc 5 -. (Bothe). 028 



936 


SUBJECT INDEX 


Hypertonic glucose solution (50 per cent). 
Intravenous Injections of, effects 
of, on circulation of cat, (Maz- 
zola and Torrey). 613 
Hypertrophy of clitoris, (Mason), 144 
Hysterectomies, abdominal, clinical patli- 
ologic study of 303 consecutive, 
(Samuels and Edlavitch), 397 
1 eport of end-results of 554 consecutive, 
(Phaneuf and Belson). 2C2 
Hysterectomy, complete placental detach- 
ment with apoplexy of uterus 
requiring (Leventhal), 748 
Hysterocele, dystocia from, in case of 
double uterus, (Schockaert), 
621 (Abst.) 

Hysterostomatomy, (Randall), 873 


Incision, Pfannenstiel, (Lindenberg), 612 
(Correspondence) 

instrument to outline, (Schochet and 
Lackner), 155 

Infants, normal newborn, blood chemistry 
studies of, (Holman and Ma 
thieu), 138 

Infection, puerperal, morbidity and mor 
tality from, prevention and con- 
trol of, by state or municipal 
supervision and inspection. (Ba- 
con). 194 

Infections, acute (extragenital), in preg- 
nancy, labor and puerperlum, 
(Greenhill), 7G0 (Collective re- 
view) 

puerperal, exogenous throat streptococci 
and, relationship between. (Kel- 
logg and Hertig). 213 

Influenza in pregnancy, labor and puer- 
perium, (Greenhill), 761 (Collec- 
tive review) 

Insemination, uterine, tubal pregnancy 
following, (Lifvendahl), 733 

Instrument facilitating atraumatic palpe- 
bral separation in newborn 
(Castallo), 451 

to outline Pfannenstiel incision, (Scho- 
chet and Lackner), 155 

Insufflation, quinine, treatment of Tricho- 
monas vaginalis, (Sure and Ber- 
cey), 136 

Interstitial fibroid, myomectomy for, com- 
plicated by very early preg- 
nancy, CVlneberg), 746 

Intestinal origin of eclampsia, (Brown), 
774 (Abst.) 

Intestines, eventration of. in postoperative 
rupture of abdominal wound. 
(Gerich), 619 (Abst.) 

Intravenous injections of hypertonic glu- 
cose solution (50 per cent), ef- 
fects of, on circulation of cat, 
(Mazzola and Torrey). 643 

Inversion of puerperal uterus, acute. 

adrenalin in treatment of. (Ur- 
ner), 131 

Involutional states, folliculin, use of. 
(Sevringhaus), 361 

Iodine, intrauterine Injection of. tubal 
patency after, (Tschertok and 
Schor), 314 (Abst.) 

Irradiation of uterus, injury of urinary 
bladder following, (Dean), 667 

Item. American Board of Obstetrics and 
Gjmecology, 164, 464, 613, 778 

K 

Kraurosis vulvae, (Goldberger), 58 


Babor, chronic hypertropliic vulvitis (ele- 
phantiasis) complicating, (Rey- 
craft and Seecof), 60S 
pregnancy and puerperlum, acute (ex- 
tragenital) infections in, (Green- 
hill), 760 (Collective review) 
subsequent to abruptio placentae and 
uteroplacental apoplexy, (Rosen- 
feld), 911 

sodium amytal in, oral administration 
of, (Van Del), 564 

spontaneous amputation of cervix dur- 
ing, (DeCosta), 557 
test of, (Rudolph). 840 
third state of, mechanism and manage- 
ment of, (Brandt). 662 
Laparotomy, Retzius space abscess fol- 
lowing, (Reeves). 897 
Laryngeal diphtheria complicating puer- 
perium, (Hersh), 133 
Lesions of placental vessels, relationship 
to pathology of placenta and ef- 
fect upon fetal morbidity and 
mortality, (Montgomery), 320 ■ 
Leucemia, lympliatic, and pregnancy, 
(Russell), 493 

Leucokraurosis (kraurosis vulvae) cured 
by vulvectomy, report of case, 
(Neustaedter), 001 

Leucoplakia of vulva followed by car- 
cinoma developing in scar of 
vulvectomy, (Plschmann). 309 
Ligament, round, tumors of, (Horine), 
446 


Ligation of ureters, accidental, during 
pelvic operations, (Newell), 220 
Lipiodol, entrance of, into ovarian and 
other veins during uterography, 
(Kilroe and Heilman), 152 
Liver, yellow atrophy of, in pregnancy, 
(Duncan and MacLachlan), 157 
Local anesthesia for gynecologic abdomi- 
nal operations, simpler, im- 
proved metliod of, (Frigyesi), 
618 (Abst.) 

Lumbar anesthesia, (Mayer), 582 (Abst.) 
Lung inflator for indirect mouth-to-mouth 
breathing in treatment of as- 
phyxia in newborn, (MacKen- 
zie). 918 

Lymph nodes, endometrioses of, (Hans- 
mann and Schenken), 572 
Lymphatic leucemia and pregnancy, (Rus- 
sell). 493 


M 

Malignancy, gynecologic, radiation ther- 
apy in, (Kaplan), 368 

Marriage, hygiene of, (Everett), 462 
(Book review) 

Mastodynia, organotherapy of, (Gabrie- 
lianz), 499 

Maternal mortalities in hospital, new 
methods of study applied to. 
(Skeel), 187 

Maternity service, mortality statistics in 
rating, use of, (Miller), 577 

Measles in pregnancy, labor and puer- 
perium, (Greenhill), 768 (Collec- 
tive review) 

Meningitis in pregnancy, labor and puer- 
perium. (Greenhill), 770 (Collec- 
tive review) 

Menopause, folliculin in involutional 
states, use of, (Sevringhaus), 
361 

Menstrual changes in tuberculous women, 
analysis of, (Jameson), 22 
endometrium, viability of fragments of, 
(Geist), 751 



SUBJECT INDEX 


937 


Menstrual— Cont’ d 

function, irregularity of, (Allen), 705 
intervals, (King), 583 
Metaphen, treatment of puerperal septi- 
cemia and other blood stream 
infections wiOi, (Bernstlne), Sib 
Morbidity and mortality from puerperal 
infection, prevention and control 
of, by state or municipal super- 
vision and inspection, (Bacon), 

m 

Morrisania Hospital, obstetrics in, ac- 
count of a year's service in. 
(Aranoiv), 42o 

Mortalities, maternal, in hospital, new 
methods of study applied to, 
(Skeel), 187 

Mortality, morbidity and, from puerperal 
infection, prevention and control 
of, by state or municipal super- 
vision and inspection, (Bacon), 
194 

statistics, use of, in rating maternity 
service. (Miller). 577 
Mother, expectant, handbook for, (Irv- 
ing), 453 (Book review) 

Mumps in pregnancy, (Greenhill), 771 
(Collective review) 

Myoma, submucous, complicating puerpe- 
rium, (Mann and Lowenburg), 
443 

Myomectomy for interstitial flbroid com- 
plicated by very early preg- 
nancy. (Vlneberg). 740 

N 

Naegele pelvis wlUi coincidental deformi- 
ties of genital tract and ex- 
tremities, (Heinberger), 834 
New York Obstetrical Society, ICO, 452, 
757 

Newborn, asphyxia In, treatment of, by 
lung inflator for indirect mouth- 
to-mouth breathing, (MacICen- 
zie). 018 

atraumatic palpebral separation in, in- 
strument facilitating, (Cas- 
tallo), 451 

cyanosis of. (Dennen), 144 

hemorrhage in, analysis of, 55 cases, 
(Dembo), 587 

infants, normal, blood chemistry stud- 
ies of, (Holman and Mathleu), 
338 

ruptured ovarian cyst in, (Dodek), 914 

sex of, simple procedure for determin- 
ing, where diagnosis is difficult 
due to genital abnormalities. 
(Witherspoon). 921 

stillborn and, congenital pneumonia of, 
(Kaldor), 113 

Nicotine, effect of, on ovaries of white 
mice, (Unbeliaun), 316 (Ahst.) 
Nomenclature of disease, standard classi- 
fied, Oil 

Nurses, gynecology for, syllabus of lec- 
tures on, (committee of Ameri- 
can Gynecological Society), 401 
(Book review) 


O 


Obstetric shock, (Alders). 550 
(Phillips), 593 (Ahst.) 


(Abst.) 


Obstetrical Society of Philadelphia, 452, 
757, 7!K 


Obstetrics, ablatio placentae followed Toy 
sloughing of uterus, (Coventry 
and Moe), 859 

abruptio placentae, (Siegel). S94 

and uteroplacental apoplexy, preg- 
nancy and labor subsequent to, 
(Rosenfeld), 911 


} Obstetrics — Cont’d 

acid base balance in pregnancy, regu- 
latory mechanism of, (Ansel- 
mino), 450 (Book review) 
adrenalin in treatment of acute inver- 
sion of puerperal uterus, 
(Urner), 131 

and gynecology, recent advances in, 
(Bourne and Williams), 456 
(Book review) 

anesthesia, epidural, (Henry and Jaur), 
621 (Ahst.) 

prolonged local, (Aburel), 621 (Ahst.) 
Aschheim-2k)ndek jJregnancy test, Fried- 
man modification, (Mann et 
al.), 723 

Schneider modification of, as re- 
lated to private practice, (Mor- 
gan) , 81G 

at Morrisania Hospital, public institu- 
tion, account of a year’s service 
in, (Aranow) , 420 

avertin in. clinical study of, (Bemis), 
677 

avitaminosis as likely etiologic factor 
in polyneuronitis complicating 
pregnancy, (Luikart), 909 
Bercovitz test for pregnancy, (King), 
99 

bilateral renal agenesis in fetus, asso- 
ciated with oligohydramnios, 
(Bates), 41 

cervix, spontaneous amputation of, dur- 
ing labor, (DeCosta), 557 
cesarean sections performed in Phila- 
delphia during 1931, survey of, 
(Bull), 426 

study of 733, (Dalchman and Pom- 
erance), 522 

complete placental detachment with 
apoplexy of uterus requiring 
hysterectomy, (Leventhal), 748 
congenital defect of diaphragm, (New- 
■berger), 306 

cord, velamentous insertion of, with 
rupture, and subsequent death 
of fetus in uterus, (Boley), 150 
cyanosis of newborn, (Dennen), 147 
death of fetus in pregnancy, (Law- 
rance), 033 

der gehurtsh ilflich-gynaekologische 
Sachverstfindlge, (HUssy) 457 
(Book review) 

diabetes and pregnancy, (Ronsheim), 
710 

dystocia from hysterocele in case of 
double uterus, (Schockaert), 621 
(Abst.) 

ectopia cordis, case of, (Llntgen), 449 
endocarditis, subacute bacterial, as 
complication of pregnancy, 
(Mengert), 121 

endometritis and pbysometra due to 
Welch bacillus, (Falls), 280 
epithelial proliferation of cervix uteri 
during pregnancy, and Its clin- 
ical Implications, (Hofbauer), 
779 


fetal heart rate, influence of carbon 
dioxide on frequency of, (Rech) 
620 (Abst.) 

fetus, spontaneous evolution of. In 
transverse presentation, (East- 
man), 582 

handbook for expectant mother, (Irv- 
ing), 458 (Book review) 
heart-block^ in^pregnant women. (Green- 


hemorrhage in newborn, analysis of 55 
cases, (Dembo), 587 
jij'sterostomatomy, (Randall). 873 
internal rotation of fetal head from 
viewpoint of Comparative (Ru- 
dolph and Ivy). 74 

Inversion of puerperal uterus, acute 
adrenalin in treatment of. (Tjr- 
ner), 131 



938 


SUBJECT INDEX 


Obstetrics — Cont’d 

labor complicated by chronic hyper- 
trophic vulvitis (elephantias.s), 
(Reycraft and Seecof), GOS 
sodium amytal in, oral administra- 
tion of, (Van Del), 5G4 
test of, (Rudolph), 840 
laryngeal diphtheria complicating puer- 
perium, (Hersh), 133 
liver, yellow atrophy of, in pregnancy 
(Duncan and MacLachlan), 157 
maternal mortalities in hospital, new 
methods of study applied to, 
(Skeel), 187 

myomectomy for interstitial fibroid 
complicated by very early preg- 
nancy, (Vineberg), 740 
Naegele pelvis with coincidental defor- 
mities of genital tract and ex- 
tremities, (Reinberger), 834 
operative, diminution of pain in, 
(Stahnke), 193 (Abst.) 
osteogenesis imperfecta, (Hennessv), 
590 

perforation of flbromyomatous uterus 
following version, (Weber), 597 
placenta accreta, conservative versus 
radical treatment, (Dorsett), 
274 

previa with twin pregnancy, (Rau- 
denbush), 752 

placental vessels, lesions of, relation- 
ship to pathology of placenta 
and effect upon fetal morbidity 
and mortality, (Montgomery'), 
320 

pneumonia, congenital, of stillborn and 
newborn. (Kaldor), 113 ‘ 
practical medical series, (DeLee), 455 
(Book review) 

pregnancy and labor subsequent to 
abruptio placentae and utero- 
placental apoplexy, (Rosenfeld), 
911 

test, modification of Friedman, 
(Vesell), 909 

prolapse, etiology of, (Graff), 800 
puerperal infection, morbidity and mor- 
tality from, prevention and con- 
trol of, by state and municipal 
supervision and inspection. (Ba- 
con), 194 

infections, exogenous throat strepto- 
cocci and, relationship between, 
(Kellogg and Hertig), 213 
sepsis, Bacillus Welchii, fatal types, 
(Lash), 2S8 

septicemia and other blood stream in- 
fections, treatment of, with 
metaphen, (Bernstine). 849 
roentgenograms, atlas of, (Diepmann 
and Danelius), 458 (Book re- 
view) 

sigmoidouterine and vesicouterine fistula 
complicating childbirth, (Kirch- 
ner), 241 

studlen fiber die veranderungen der 
nachgeburt bel lues, (Olin), 457 
(Book review) 

submucous myoma complicating puerpe- 
rium, (Mann and Lowenberg), 
443 

third stage of labor, meclianism and 
management of, (Brandt). 602 
toxemias of pregnancy, (Solomons), 172 
toxic psychoses of pregnancy and puer- 
perium, (McGoogan) , 792 
Tradtado de obstetricia. (Recasens). 
457 (Book review) 

tubal pregnancy at term, (Wechsler). 
600 

umbilical cord relatively shortened bv 
> coiling about neck of fetus. 
(Zehm), 923 

ureteronephrectomy during early preg- 
nancy. (McKnight and Patter- 
son), 141 


Obstetrics — Cont’d 

uterus, puerperal, acute inversion of. 
adrenalin in treatment of. (Ur- 
ner). 131 

varicose veins of pregnancy, (Kil- 
bourne), 104 

Oligohydramnios, bilateral renal agenesis 
in fetus, associated with, 
(Bates), 41 

Operation, foreign bodies left in abdo- 
men after, (Greenhill), 231 
Operations, plastic, on breast, (Glasmer), 
402 (Book review) 

Organotherapy of mastodynia. (Gabrie- 
lianz), 499 

Osmosis of nutriment, impaired placen- 
tal, (Dawrance), 633 

Osteogenesis imperfecta, (Hennessy), 590 
Ovarian aplasia, unilateral, and homo- 
lateral rudimentary fallopian 
tube associated with normally 
developed uterus, (De Sanctis 
and Diaslo), 002 

blood-cysts, rupture of, simulating 
acute appendicitis, (Boggan and 
Wrigley), 98 (Abst.) 
cyst, ruptured, in newborn, report of 
case. (Dodek), 914 
torsion of, with bradycardia, (Mat- 
ters), 193 (Abst.) 

embryoma, report of case, (Sarma), 51 
fibroid, report of case, (Alsobrook). 609 
struma, morphologic, pharmacologic, 
and biologic examination, 
(Plant), 351 

Ovaries of white mice, effect of nicotine 
on, (Unbehaun), 316 (Abst.) 
Ovary, adenoma of, testicular tubular, 
(Popoff). 617 (Abst.) 
bone formation, non-teratomatous (Set- 
tergren), 617 (Abst.) 
granulosa cell hyperplasia of, (Brewer 
and Jones), 503 

multiple dermoids of, (Miller), 252 
tubular adenoma (arrhenoblastoma) of, 
(Spielman), 517 

P 

Pain, diminution of, in operative gyne- 
cology and obstetrics, 
(Stahnke), 193 (Abst.) 
in carcinoma of cervix, pelvic sympa- 
thectomy for. (Behney), 687 
Palpebral separation in newborn, instru- 
ment facilitating, (Castallo), 
451 

Patency of tubes after intrauterine in- 
jection of iodine, (Tschertok and 
Schor), 314 (Abst.) 

Pelvic spleen with torsion of pedicle, 
(Bullard). 599 

sympathectomy for pain in carcinoma 
of cervix, (Behney), 087 
Pelvis. Naegele, with coincidental defor- 
mities of genital tract and ex- 
tremities. (Reinberger), 834 
Perforation of fibromyomatous uterus^ 
following version, (Weber). 597 
Pessary, stem, embedded in uterus for 
fifteen years, (Adair). 750 
Pfannenstiel incision. 612 

instrument to outline, (Schochet and 
Lackner), 155 

Placenta, ablatio placentae followed bj' 
sloughing of uterus, (Coventry 
and Moe), 859 

abruptio placentae, (Siegel), 894 

and uteroplacental apoplexy, preg- 
nancy and labor subsequent to, 
(Rosenfeld). 911 

accreta, conservative versus radical 
treatment, (Dorsett); 274 
detached, respiratory' function, (Bran- 
dau), 95 

previa with twin pregnancy, (Rauden- 
bush). 752 



SXTBJECT INDEX 


939 ’ 


Placental detachment, complete, with 
apoplexy of uterus requiring: 
hysterectomy, (Leventhal), 74S 
osmosis, impaired, of nutriment, (Law- 
rance), 033 

vessels, lesions of, relationship to path- 
ology of placenta and effect 
upon fetal morbidity and mor- 
tality, (Montgomery), 320 

Plague in pregnancy, labor and puerpe- 
rlum. (Greenhill), 771 (Collec- 
tive review) 

Pneumonia, congenital, of stillborn and 
newborn. (Kaldor), 113 
In pregnancy, labor and puerperium, 
(Greenhill), 762 (Collective re- 
view) 

Polyneuronitis complicating pregnancy, 
avitaminosis as likely etiologic 
factor in, (Luikart), 810 

Postmenopausal bleeding. (Geist and 
Matus), 388 

Preeclampsia and eclampsia, prophylaxis 
and treatment of, (Seitz), 774 
(Abst.) 

Preeclamptic and eclamptic women. late 
results in cases of, (Kobes) , 775 
(Abst.) 

Pregnancy, abdominal, complicated by 
eclampsia, (Allen), 753 
acid base balance in, regulatory mech- 
anism of, (Anselmlno), 456 
(Book review) 

amniotlc fluid, volumetric determina- 
tion of. with Congo red, (Dieck- 
mann and Davis), 023 
artlflclal abortion, indications and 
methods of, (Winter), 403 (Book 
review) 

Aschheim-Zondek test, Sehneider modi- 
fication of, as related to private 
practice, consideration of, (Mor- 
gan), 81(5 

Bercovitz test for, (King), 99 
death of fetus in, (Lawrance), 033 
diabetes and. (Ronsheim), 710 
epithelial proliferation in cervix uteri 
during, and its clinical implica- 
tions, (Hofbauer), 779 
handbook for expectant mother, (Irv- 
ing), 458 (Book review) 
hypertliyroiclism associated witli, 
(Bothe), 028 

labor, and puerperium, acute (extra- 
genital) infections in. (Green- 
hill). 700 (Collective review) 
subsequent to abruptio placentae and 
uteroplacental apoplexy, (Rosen- 
feld). Oil 

liver, yellow atrophy of, in. (Duncan 
and MacLachlan), 157 
lymphatic leucemia and. (Russell), 493 
myomectomy for interstitial fibroid by 
very early, (Vineberg), 740 
pycliti.s of. vesicoureteral reflux as 
etiologic factor in. (Morris and 
Brunton), 414 

polynouronitis complicating, avltamino- 
.sls as likely etiologic factor in. 
(Luikart). 810 

puerperal sepsis. Bacillus Welchii. fatal 
types. (Lash), 288 

puerperium and, toxic psychoses of, 
(McGoogan), 792 

pupillan.- tc.st for diagnosis of, (Berco- 
vitz). 882 

subacute bacterial endocarditis as com- 
plication of, (Mongert), 121 
tc.st, Aschheim-Zondek. Friedman modi- 
flcatlon, (Mann et ah). 723 
modlllcntlon of Friedman. (Yesell) 
909 

toxemias of. (Solomons). 172 
tubal at term. (Wecli.sler). 000 
following uterino in.semination, (Lif- 
vcndahl), 733 

twin. pTneenta nrovia with. (Raudon- 


Pregnancy — Cont’d 

ureteronephrectomy during early, (Mc- 
Knight and Patterson), 141- 
varicose veins of, (Kilbourne), 104 
Pregnant women heart-block in, (Green- 
hill), 125 

Presentation, transverse, spontaneous evo- 
lution of fetus In, (Eastman), 


Prolapse, etiology of, (Graff), 800 
of female pelvic viscera, (Roberts), 400 
(Book review) 

of uterus, (Coventry and Moe), 257 
and constitution. (Nakawaga), 163 
(Abst.) 

Proliferation, epithelial, in cervix uteri 
during pregnancy and its clin- 
ical implications, (Hofbauer), 
779 


Pseudohermaphrodite, feeble-minded, for- 
eign bodies found in vagina of, 
(Llfvendahl), 150 

Psychogenic factors in functional female 
disorders, (Homey), 094 
Psychoses, toxic, of pregnancy and puer- 
perium, (McGoogan). 792 
Puerperal gynecology, (Bubis), 620 
(Abst.) 

infection, morbidity and mortality from, 
prevention and control of, by 
state or municipal supervision 
and inspection, (Bacon), 194 
infections, exogenous throat strepto- 
cocci and, relationship between, 
(Kellogg and Hertig), 213' 
sepsis, B. 'Welchii. fatal types, (Lash), 
2SS 

septicemia and other blood stream in- 
fections, treatment of, with 
metaphen, (Bernstine), 849 
uterus, acute inversion of, adrenalin in 
treatment of, (Urner), 131 
Puerperium, laryngeal cliphtlieria compli- 
cating, (Hersh), 133 
pregnancy and labor, acute (extra geni- 
tal) infections in. (Greenhill), 
769 (Collective review) 
toxic psychoses of, (McGoogan). 792 
submucous myoma comolicat'ng, (Mann 
and Lowenburg), 443 
Pupillary test for diagno«;is of pregnancy, 
(Bercovitz), 882 

P.velitis of pregnanev. vesicoureteral re- 
flux as etiologic factor in, (Mor- 
ris and Brunton), 414 


Q 

Quinine insufflation treatment of Tricho- 
monas vaginalis, (Sure and Eer- 
cey), 130 

R 


Rabbits, .sex ratio among, attempts to 
influence, according to proce- 
dure of XTnterber'ger. (Unterber- 
ger and Kirscli), 425 (Abst.) 

Radiation therapy in gynecologic malig- 
nancy, (Kaplan). 308 
In uterine carcinomas, technic of 
(Schmitz), 10 

Radiologic maxi m s. (Swanberg), 403 
(Book review) 

Radium therapy, complications of, in 
, gj'necoIog>', (Ward). 1 

Reflux, vesicoureteral, etiologic factor in 
pyelitis of pregnancy, (Morris 
and Brunton). 414 

Regeneration, epithelial, in uterine glands 
and on .surface of uterus, 
(Papanicolaou), 30 

Renal agene.=is. bihateral. in fetus, asso- 
ciated with oligohydramnios 
(Bates). 41 

function, examinations of, in eclampsi.a 
and ailiftd toxemias. (Olsen) 

•r> . (Abst.) 

Respirator!- function of dpt.ached ' pl.-i- 
centa, (Brandau). 9.7 



940 


SUBJECT INDEX 


Retina, detachment of, in eclampsia, 
(Klaften), 776 (Abst.) 

Retzius space abscess following’ laparot- 
omy, (Reeves), 897 

Roentgen control of tubal sterilization, 
(Fuchs and Lork), 314 (Abst.) 

Roentgenograms, atlas of, (Liepmann and 
Danelius), 458 (Book review) 

Rotation, Internal, of fetal head from 
viewpoint of comparative ob- 
stetrics, (Rudolph and Ivy), 74 

Round ligament, tumors of, (Horine), 446 

Rupture of abdominal wound, eventration 
of intestines in, (Gerich), 619 
(Abst.) 

of graafian follicle, corpus luteum and 
small follicle or lutein cysts 
simulating appendicitis. (Meigs 
and Hoyt), 532 

of ovarian blood-cysts simulating acute 
appendicitis, (Boggan and Wrig- 
ley), 98 (Abst.) 

S 

Salpingitis, imilateral hematocolpos and. 

incomplete bipartite uterus with, 
(Carrington), 924 

Sarcomatous change, true, in uterine fi- 
broid, (Scofield), 920 
degeneration, fibroma of vulva with, 
report of case. (Nelson), 594 

Scalp, congenital defects of, (Ingalls), 
861 

Scarlet fever in pregnancy, labor and 
puerperium, (Greenhill), 763 
(Collective review) 

Schneider modification of Aschheim-Zon- 
dek test as related to private 
practice, consideration of, (Mor- 
gan), 816 

Sections, cesarean, performed in Phila- 
delphia during 1931, survey of, 
(LuU). 426 

Sedimentation test, filament-nonfilament, 
and white cell count in gynecol- 
ogy, (Yates et al.). 203 

Sepsis, puerperal, B. Welchil, fatal types, 
(Lash), 288 

Septicemia, puerperal, and other blood 
stream infections, treatment of, 
with metaphen, (Bernstine), 849 

Sex of newborn, simple procedure for de- 
termining, where diagnosis is 
difficult due to genital abnor- 
malities, (Witherspoon), 921 
ratio among rabbits, attempts to in- 
fluence, according to procedure 
of Unterberger, (Unterberger 
and Kirsch). 425 (Abst.) 

Shock, obstetric, (Alders), 550 (Abst.) 

(Phillips). 593 (Abst.) 

Sigmoidouterine and vesicouterine fistula 
complicating childbirth, (Kirch- 
ner). 241 

Smallpox in pregnancy, labor and puer- 
perium, (Greenhill), 767 (Col- 
lective review) 

Snake venom (Ancistrodon piscivorus), 
treatment of uterine bleeding 
with, (Peck and Goldberger), 
887 

Society transactions, American Associa- 
tion of Obstetricians. Gynecolo- 
gists and Abdominal Surgeons, 
310 

Brooklyn Gynecological Societj’, 160, 
611 

Central Association of Obstetricians 
and Gjmecologists. 926 

Chicago Gj-necological Society, 160, 
311, 611. 758. 759 

New York Obstetrical Society, 160. 
452, 757 

Obstetrical Societj’’ of Philadelphia, 
452, 757, 758 


Sodium amj’tal, oral administration of, 
in labor. (Van Del), 564 
Specialist, qualifications of, (Dannreu- 
ther), 165 

Speculum for use in cervical cauteriza- 
tion, (McLaughlin). 755 
Sperm morphology and biometrics, do 
they reallj’’ offer reliable index 
of fertility, (Moench), 410 
Spermatozoa, human, head lengths of, 
biometrical studies of, (Moench 
and Holt), 313 (Abst.) 

Spinal anesthesia and chloroform admin- 
istered at same time, dangers 
of, (Garlpuj’), 620 (Abst.) 
Spleen, pelvic, with torsion of pedicle. 
(Bullard). 599 

Starvation, fetal, (Lawrance), 633 
Statistics, mortality, use of, in rating 
maternity service, (Miller). 577 
Stem pessary embedded in uterus for fif- 
teen years, (Adair), 750 
Sterile couples, examining, methods of. 

(Moench), 312 (Abst.) 

Sterllitj', amenorrhea and, small doses of 
x-ray for, (Edeikon), 511 
female, role of appendicitis in etiology 
of, (Rubin). 312 (Abst.) 
nicotine, effect of, on ovaries of white 
mice, (Unbehaun), 316 (Abst.) 
restorative surgery of fallopian tubes, 
methods and results of, (Serdu- 
koff), 313 (Abst.) 

spermatozoa, human, head lengths of, 
biometric studies of, (Moench 
and Holt), 313 (Abst.) 
tubal patency after intrauterine injec- 
tion of iodine, (Tschertok and 
Schor), 314 (Abst.) 

Sterilization, hormonal, of animals, 
(Mandelshtam and Tschaikov- 
sky), 315 (Abst.) 

question of, (Horneffer), 315 (Abst.) 
human, history of sexual sterilization 
movement, (Landman), 461 
(Book review) 

of animals without use of hormones. 

(Tschaikowsky), 316 (Abst.) 
regeneration of resected tubes, experi- 
mental study on, (Vignes and 
Baron), 314 (Abst.) 

reversible (temporary), of female by 
crushing fallopian tube. (Nau- 
joks). 315 (Abst.) 

tubal, roentgen control of, (Fuchs and 
Lork), 314 (Abst.) 

Stillborn and newborn, congenital pneu- 
monia of, (Kaldor), 113 
Streptococci, exogenous throat, and puer- 
peral infections, relationship be- 
tween, (Kellogg and Hertig), 
213 

Streptococcus in Trichomonas vaginalis 
vaginitis, significance of, (Hib- 
bert). 465 

Struma, ovarian, morphologic; pharma- 
cologic. and biologic examina- 
tion, (Plant), 351 

Submucous mj’oma complicating puerpe- 
rium, (Mann and Lowenburg), 
443 

Superfetation, experimental production 
of. (Wislocki and Snyder), 163 
(Abst.) 

Supports of uterus, (Koster), 67 
Surgery. gj’’necologlcal. consen'ative. 
(Bell), 619 (Abst.) 

Sympathectomy, pelvic, for oain in car- 
cinoma of cerj’lx, (Behney). 687 

T 

Teratoma of uterus, report of case. 

(Lackner and Krohn), 735 
Test of labor, (Rudolph), 840 

pregnancv. rnodiflcation of Friedman. 

' (Vesell), 909 



SUBJECT INDEX 


941 


Test of — Cont’d 


pupillary, for diagnosis of pregnancy, 
(Bercovitz), 882 

sedimentation, fllament-nonfllament, and 
white cell count in gynecology, 
(Yates et al.), 203 

Testicular tubular adenoma of ovary, 
(Popoff), C17 (Abst.) 

Tetanus in pregnancy, labor and puerpe- 
rium, (Greenhill), 770 (Collec- 
tive review) 

Third stage of labor, mechanism and 
management of, (Brandt), C62 

Torsion of ovarian cyst with bradycardia, 
(Matters), 103 (Abst.) 

•toxemias of pregnancy, some phases of, 
(Solomons), 172 ' 

Tratado de obstetrlcia (Kecasens), 457 
(Book review) 

Trichomonas vaginalis (DonnS), (Stein 
and Cope), 819 

quinine insufllatlon treatment of, 
(Sure and Bercey), 130 
vaginitis, significance of streptococ- 
cus in, (Hibbert), 405 

Tubal contractions in relation to estrus 
cycle as determined by utero- 
tubal insufflation, (Whitelaw), 
475 

patency after intrauterine injection of 
iodine, (Tschertok and Schor), 
314 (Abst.) 

pregnancy at term, (Wechsler), GOO 
following uterine insemination, (Uif- 
vendahl), 733 

sterilization, roentgen control of, (Fuchs 
and Lork), 314 (Abst.) 

Tube, fallopian, homolateral rudimentary, 
unilateral ovarian aplasia and, 
associated with normally de- 
veloped uterus, case of, (De 
Sanctis and Diaslo), 002 
reversible sterilization of female by 
crushing, (Naujoks), 315 (Abst.) 

Tuberculosis of female genital tract, 
(Busch), 508 

genital, in women, (Daniel), 400 (Book 
review) 

Tuberculous infection, adenomyoma (ade- 
nomyosis of Frankl) of uterus 
with, (Rigdon), 902 

endometritis, (Reinhart and Moore), 
102 (Abst.) 

women, menstrual changes in, analy- 
sis of, (Jameson), 22 

Tubes, fallopian, restorative surgerj’- of. 

methods and results of, (Serdu- 
koff), 313 (Abst.) 

resected, experimental study on regen- 
eration of, (Vignes and Baron), 
314 (Abst.) 

Tubular adenoma (arrhenoblastoma) of 
ovary, (Spielman), 517 
of ovary, testicular, (Popoff), 017 
(Abst.) 

Tumors of round ligament, (Horine). 440 

Twin pregnancy, placenta previa with. 
(Raudenbush), 752 

Typlioid fever in pregnancy, labor and 
puorperlum. (Greenhill), 700 
(Collective review) 


U 


Ureterovesical anastomosis, results after 
twelve years in case of, (Fur- 
niss), 154 

Ureters, injury to, including accidental 
ligation during pelvic opera- 
tions, (Newell), 220 

Urinary bladder, gummas of, (Levy and 
Tripoli). 743 

injury of, following irradiation of 
uterus, (Dean), 007 

retention, postoperative, treatment of, 
(Kottlors), 159 (Abst.) 
tract fistulas, causes and treatment of, 
with special reference to method 
of four catgut layers, (Apaja- 
laliti), 018 (Abst.) 

Urologic complications in female, (Ko- 
lischer). 128 

Uteri, cervix, epithelial proliferation in, 
during pregnancy, and its clin- 
ical implications, (Hofbauer), 
779 

Uterine bleeding, treatment of, with 
snake venom (Ancistrodon pis- 
civorus), (Peck and Goldber- 
ger), 887 

carcinomas, radiation therapy in, tech- 
nic of. (Schmitz), 10 
cervic, conization of, (Hyams). 053 
fibroid, true sarcomatous change in, 
(Scofield), 920 

glands, epithelial regeneration in, and 
on surface of uterus, (Papani- 
colaou), 30 

Insemination, tubal pregnancy follow- 
ing, (Lifvendahl). 733 

Uterography, entrance of lipiodol into 
ovarian and other veins during, 
(Kilroe and Heilman), 152 

Uteroplacental apoplexy and abruptlo 
placentae, pregnancy and labor 
subsequent to, (Rosenfeld), 911 

Uterus, adenomyoma (adenomyosis of 
Frankl) of, with tuberculous In- 
fection, (Rigdon), 902 
complete placental detachment with 
apoplexy of, requiring hysterec- 
tomy. (Deventlial) . 748 
double, dystocia from hysterocele, 
(Schockaert), 621 (Abst.) 
duplex, (Haynes), 004 
incomplete bipartite, witii unilateral 
hematocolpos and salpingitis, 
(Carrington), 924 

irradiation of, injury of urinary blad- 
der following, (Dean), 007 
perforation of flbromyomatous. follow- 
ing version. (Weber), 597 
prolapse of, (Coventry and Moe), 257 
and constitution, (Nakawaga), 103 
(Abst.) 

puerperal, acute inversion of, adrenalin 
in treatment of, (Urner), 131 
rudimentary bicornate, in right crural 
•hernia, (Arenas), 022 (Abst.) 
sloughing of, following ablatio placen- 
tae, (Coventry and Moe), 859 
stem pessary embedded in, for fifteen 
years. (Adair), 730 
supports of, (ICoster), 67 
surface of, epithelial regeneration in 
uterine glands and on, (Papani- 
colaou), 30 

teratoma of, report of case, (Lackner 
and ICrohn), 735 


Umbilical cord relatively shortened by 
coiling about neck of fetus'. 
(Zehm), 923 

Ureter, lesions of pelvic, produced during 
course of g>-necologic inteiwen- 
inccnt). CIS (Abst.) 

Uixtcronephrectomy during carlv preg- 
nancy. (McKnight and ’ Patter- 
son), 141 


\agina, fascia and surrounding origin 
and arrangement, (Sears), 484 
foreign bodies in. of feeble-minded 
pseudohermaphrodite, (Lifven- 
dahl). 150 

injuries to. resulting from Elliott treat- 
ment, (Cosgrove and Waters), 



942 


SUBJECT INDEX 


cjtj-p Vaginal and cervical cultures, technics 
for taking, bacteriologic study 
of, (Adair et al.), 551 
vault, granuloma of, (Sears), 900 
Vaginitis, Aspergillus fumigatus, (Gold- 
stine), 750 

Doderlein’s bacillus in treatment of, 
(Mohler and Brown), 718 
Trichomonas vaginalis (Donnd), (Stein 
and Cope), 819 

Varicella in pregnancy, labor and puer- 
perium, (Greenhill), 708 (Col- 
lective review) 

Varicose veins of pregnancy, (Kllbourne), 
101 

Veins, varicose, of pregnancy, (Kll- 
bourne), 104 

Vesicoureteral reflux as etiologic factor 
in pyelitis of pregnancy, (Mor- 
ris and Brunton), 414 
Vesicouterine flstula, sigmoidouterlne and, 
complicating childbirth, (ICirch- 
ner), 241 

Vessels, placental, lesions of, relationship 
to pathology of placenta and ef- 
fect upon fetal morbidity and 
mortality, (Montgomery), 320 
Viability of fragments of menstrual en- 
dometrium, (Geist), 751 
Viscera, female pelvic, prolapse of, 
(Roberts), 4G0 (Book review) 
Vulva, fibroma of, with sarcomatous de- 
generation, report of case, (Nel- 
son), 594 


Vulva — Cont’d 

leucoplakia of, followed by carcinoma 
developing in scar of vulvec- 
tomy, (Flsclmiann),-309.. . . 

Vulvae. kraurosis; (Goldberger), 58 

Vulvectomy, carcinoma developing in scar 
of, following leucoplakia of 
vulva, (Fischmann), 309 
leucokraurosis (kraurosis vulvae) cured, 
by, report of case, (Neustaed- 
ter), 601 

Vulvitis, chronic hypertrophic (eleplian- 
tiasis) complicating labor, (Rey- 
craft and Seecof), GOS 

W 

Welch bacillus, endometritis and physo- 
metra due to, (Falls), 280 

White cell count, sedimentation test, fila- 
ment-nonfllament and, in gyne- 
cology, (Tates et al.), 203 

Whooping cougli in pregnancy and puer- 
periuni, (Greenhill), 771 (Collec- 
tive review) 

Wisdom of body, (Cannon), 4G1 (Book re- 
view) 

Women, eclamptic and preeclamptic, late 
results in cases of, (Kobes), 775 
(Abst.) 

Wound, rupture of abdominal, eventra- 
tion of intestines in. (Gerich), 
619 (Abst.) 

X 

X-ray for amenorrhea and sterility, small 
doses of, (Edeikon), 511